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Guntin J, Regalado L, Serhal A, Omar IM, Hsu WK, Garg A. Safety outcomes and improvement in pain scores after radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection. Skeletal Radiol 2024; 53:1145-1152. [PMID: 38110779 DOI: 10.1007/s00256-023-04548-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Image-guided spine injections are an important tool in the management of patients with a variety of spinal pathologies. Our practice offers radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection (ESI) routinely performed in the outpatient setting. The purpose of this study was to evaluate clinical outcomes and improvement in pain scores after radiologist-performed cervical ESI. METHODS An institutional database was used to retrospectively identify cervical injections performed between October 2016 and October 2022. All injections were performed at the C7-T1 level utilizing 1.0 mL of 10 mg/mL dexamethasone without epidural anesthetic. The Numerical Rating Scale (NRS) was used to assess pain improvement. Cervical MRI was reviewed to assess pre-injection cervical disease severity. Patient charts were reviewed for any post-injection complications. RESULTS A total of 251 cervical injections in 186 patients met our inclusion criteria with mean clinical follow up of 28.5 months (range 0.2 - 73.0 months). No patients experienced any major complications after injection. Post-injection pain scores were available for 218 of 251 injections (86.9%) with mean follow-up of 11.8 days (range 6 - 57 days). There was a significant improvement in pain scores from a mean pre-injection NRS score of 5.2/10 to 3.0/10 (p < .0001). 117 patients (53.7%) reported ≥ 50% improvement after injection. Patients who had prior injection were more likely to report ≥ 50% pain improvement after subsequent injection (p = .012). CONCLUSION Radiologist-performed fluoroscopy-guided interlaminar cervical ESI at the C7-T1 level is a safe and effective tool in the management of patients with cervical pathology.
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Affiliation(s)
- Jonathan Guntin
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA.
| | - Luis Regalado
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Ali Serhal
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Imran M Omar
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Wellington K Hsu
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Ankur Garg
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
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Tang Z, Liu J, Li J, Ma C. Use of bone landmarks for assessing the safety of acupuncture on the posterior midline of the neck region. BMC Complement Med Ther 2024; 24:168. [PMID: 38649990 PMCID: PMC11034117 DOI: 10.1186/s12906-024-04466-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVE Many acupuncture acupoints are located on the posterior midline of the neck region. The needling depth for acupuncture is important for practitioners, and an unsafe needling depth increases the possibility of damage to the spinal cord and brainstem. Can the safety of acupuncture be assessed by examining bone structures? We focused on this aim to carry out this study. METHODS The shortest distance from the posterior border of the foramen magnum to the line joining both upper ends of the posterior border of the mastoid process was measured on 29 skulls. Distances from the posterior border of the vertebral foramen to the tip of the spinous process and posterior tubercle of the atlas were measured and evaluated from 197 dry cervical vertebrae and 31 lateral cervical radiographs of patient subjects. The anatomic relationships of the vertebral canal with the external occipital protuberance, tip of the spinous process of the axis, tip of the posterior tubercle of the atlas, and upper end of the posterior border of the mastoid process were observed and evaluated via lateral cervical radiography. RESULTS The shortest distance from the foramen magnum to the line between the mastoid processes was 4.65±1.75 mm, and the distance from the superior border of the vertebral foramen of the atlas to the posterior tubercle was less than the distance from the inferior border. The distance from the superior border of the vertebral canal to the tip of the spinous process in C2-C7 was greater than the distance from the inferior border. The mean lengths of the superior border of the C2 spinous process and the inferior border of the C7 spinous process were greater than 21 mm and 31 mm, respectively. The line from the upper end of the posterior border of the mastoid process to the tip of the C2 spinous process or 10 mm deep to the tip of the C2 spinous process was posterior to the vertebral canal. CONCLUSIONS On the posterior midline of the neck region between the tip of spinous process of axis and external occipital protuberance, if the needle reaches the depth of the line between the upper end of posterior border of mastoid process and the tip of the spinous process of the axis, approximately 10 mm along the spinous process of the axis, the needle is in the safe region. The mean length of the C2-C7 spinous process is suitable to accommodate the needling depth of the adjacent acupoint. Bone structures can be used to effectively assess the safety of acupuncture on the posterior midline of the neck region.
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Affiliation(s)
- Zhiliang Tang
- Department of Human Anatomy, School of Basic Medicine Sciences, Weifang Medical University, 7166 Baotongxi Street, Weicheng District, Weifang, 261053, Shandong, China
| | - Jiao Liu
- Department of Human Anatomy, School of Basic Medicine Sciences, Weifang Medical University, 7166 Baotongxi Street, Weicheng District, Weifang, 261053, Shandong, China
| | - Jin Li
- Department of Human Anatomy, School of Basic Medicine Sciences, Weifang Medical University, 7166 Baotongxi Street, Weicheng District, Weifang, 261053, Shandong, China
| | - Chunming Ma
- Department of Human Anatomy, School of Basic Medicine Sciences, Weifang Medical University, 7166 Baotongxi Street, Weicheng District, Weifang, 261053, Shandong, China.
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Chen YC, Yang FC, Huang GS, Chang WC, Hsu YC. Value of CT in targeted CT-guided epidural blood patching: Predictors for successful epidural punctures. J Neuroradiol 2024; 51:204-209. [PMID: 37758171 DOI: 10.1016/j.neurad.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/24/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND PURPOSE Differentiating epidural from intrathecal punctures before computed tomography (CT)-guided epidural blood patching (EBP) is subjective, relying on operator experience. This study aimed to investigate CT findings for epidural and intrathecal punctures and identify reliable predictors for successful epidural punctures before targeted CT-guided EBP. MATERIALS AND METHODS We included 65 patients with low-cerebrospinal fluid (CSF)-pressure headache receiving targeted CT-guided EBP between January 2021 and October 2022 in this retrospective study. We analyzed clinical data, technical information, and CT features before EBP. Fisher's exact test was used for discrete variables, while Mann-Whitney U test was used for continuous variables. Positive (PLR) and negative likelihood ratios (NLR) were calculated to identify predictors for confirming epidural punctures. RESULTS We confirmed 43 patients as epidural punctures and 22 patients as intrathecal punctures. Before contrast injection, epidural fat at the needle tip in the epidural group was higher than the intrathecal group (37.2 % [16/43] vs. 4.5 % [1/22], p = 0.006). After contrast injection, the "contrast-needle tip connection" sign was mostly observed in the epidural group than the intrathecal group (95.3 % [41/43] vs. 9.1 % [2/22], p < 0.001). Additionally, the epidural group had significantly higher boomerang-shaped contrast morphology than the intrathecal group (65.1 % [28/43] vs. 9.1 % [2/22], p < 0.001). The "contrast-needle tip connection" sign had the highest PLR (10.49) and lowest NLR (0.05). CONCLUSION Identifying epidural fat at the needle tip, "contrast-needle tip connection" sign, and boomerang-shaped contrast morphology on CT scans are useful for confirming proper placement of the needle tip within the epidural space.
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Affiliation(s)
- Ya-Che Chen
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan; Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan
| | - Yi-Chih Hsu
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Chenggong Rd., Neihu Dist. 114, Taipei, Taiwan.
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Lee E, Lee JW, Kang HS. Interlaminar versus transforaminal epidural steroid injections: a review of efficacy and safety. Skeletal Radiol 2023; 52:1825-1840. [PMID: 35859019 DOI: 10.1007/s00256-022-04124-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 02/02/2023]
Abstract
Spine intervention is an important treatment option for the management of spinal pain, and the numbers of the most representative epidural steroid injection (ESI) procedures performed are expected to increase significantly in the future along with increased life expectancy and the increasing prevalence of spinal disorders. Therefore, it is important to understand the efficacy of ESIs according to each spinal disorder they are administered to treat, and one must be familiar with the possible complications. In fact, although numerous ESI-related articles have been published, there is still considerable controversy regarding the efficacy of ESI procedures. Furthermore, due to the rarity of serious complications, most instances have been recorded in the form of case reports. In this article, we aimed to review the indications of cervical and lumbar ESIs and to compare interlaminar ESI (ILESI) and transforaminal ESI (TFESI) techniques in terms of analgesic efficacy, possible complications, and safety profiles. This article includes opinions based on the authors' experience with ESI indications and efficacy, and presents practical tips for coping with specific situations related to each complication. By combining the dedicated anatomical understanding of radiologists with image-guided interventions, ESI is expected to stand out in the rapidly expanding field of spine intervention.
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Affiliation(s)
- Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gumi-dong, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Gumi-dong, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Gumi-dong, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Wadhwa H, Varshneya K, Stienen MN, Veeravagu A. Do Epidural Steroid Injections Affect Outcomes and Costs in Cervical Degenerative Disease? A Retrospective MarketScan Database Analysis. Global Spine J 2023; 13:1812-1820. [PMID: 34686085 PMCID: PMC10556907 DOI: 10.1177/21925682211050320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To investigate the effect of preoperative epidural steroid injection (ESI) on quality outcomes and costs in patients undergoing surgery for cervical degenerative disease. METHODS We queried the MarketScan database, a national administrative claims dataset, to identify patients who underwent cervical degenerative surgery from 2007 to 2016. Patients under 18 and patients with history of tumor or trauma were excluded. Patients were stratified by ESI use at 3, 6, 12, 18, and 24 or more months preoperative. Propensity score matched controls for these groups were obtained. Baseline demographics, postoperative complications, reoperations, readmissions, and costs were compared via univariate and multivariate analysis. RESULTS 97 117 patients underwent cervical degenerative surgery, of which 29 963 (30.7%) had ESI use at any time preoperatively. Overall, 90-day complication rate was not significantly different between groups. The ESI cohorts had shorter length of stay, but higher 90-day readmission and reoperation rates. ESI use was associated with higher total payments through the 2-year follow-up period. Among patients who received preoperative ESI, male sex, history of cancer, obesity, PVD, rheumatoid arthritis, nonsmokers, cervical myelopathy, BMP use, anterior approach, 90-day complication, 90-day reoperation, and 90-day readmission were independently associated with increased 90-day total cost. CONCLUSION ESI can offer pain relief in some patients refractory to other conservative management techniques, but those who eventually undergo surgery have greater healthcare resource utilization. Certain characteristics can predispose patients who receive preoperative ESI to incur higher healthcare costs.
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Affiliation(s)
- Harsh Wadhwa
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Martin N. Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
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Choi DY, Lee SE, Lee MW, Lee KH, Kang E, Kwon JY, Lee HS, Kim DC. Prediction of the Cervical Epidural Space Depth from the Skin Using Cervical X-Ray, During Cervical Epidural Block with Paramedian Approach. J Pain Res 2023; 16:2079-2090. [PMID: 37351196 PMCID: PMC10284158 DOI: 10.2147/jpr.s409347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/09/2023] [Indexed: 06/24/2023] Open
Abstract
Objective The purpose of this study is to compare the actual needle depth measured during cervical epidural block (CEB) with the predicted needle depth measured through a cervical flexion x-ray image at the paramedian approach. Methods The study was conducted based on the medical records of patients who underwent CEB at the pain clinic of Haeundae Paik Hospital. The actual needle distance (AD) was recorded after each successful CEB. The distance from the spinolaminar line to the skin, predicted median depth (PMD), was measured using lateral x-ray images. The medial to lateral distance (MLD), which is the distance from the midline of the spine to the needle insertion point, was measured using anteroposterior (AP) x-rays. The predicted paramedian depth (PPD) was calculated using the Pythagorean formula. The PMD represents the expected depth of the median approach, while the PPD represents the expected depth of the paramedian approach. The PMD, PPD, and AD were compared with each other. Results Concordance correlation coefficient (CCC) and Bland-Altman analysis were obtained for PMD and PPD. The CCC value of PMD was measured as 0.829, and the CCC value of PPD was measured as 0.830. In the Bland-Altman analysis, PPD was measured at -0.13 ± 8.37 mm, and PMD was measured at 1.29 ± 8.38 mm. Conclusion When performing CEB through the paramedian approach, the depth can be predicted using a cervical flexion x-ray. At this time, the PMD can also be used to predict the depth during the paramedian approach.
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Affiliation(s)
- Dae Yun Choi
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Sang Eun Lee
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Min Woo Lee
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Ki Hwa Lee
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Eunsu Kang
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Ji Yeon Kwon
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Hyun-Seong Lee
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
| | - Dong-chun Kim
- Department of Anesthesiology and Pain Medicine, Inje University Haeundae Paik Hospital, Busan, South Korea
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Maeda M, Maeda N, Masuda K, Kamatani Y, Takamasa S, Tanaka Y. Ligamentum Flavum Rupture by Epidural Injection Using Ultrasound with SMI Method. Tomography 2023; 9:285-298. [PMID: 36828375 PMCID: PMC9964737 DOI: 10.3390/tomography9010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023] Open
Abstract
The loss of resistance (LOR) method has been used exclusively to identify epidural space. It is difficult to find the epidural space without the risk of dural puncture. Various devices have been developed to improve the accuracy of the LOR method; however, no method has overcome the problems completely. Therefore, we devised a ligamentum flavum rupture method (LFRM) in which the needle tip is placed only on the ligamentum flavum during the epidural injection, and the injection pressure is used to rupture the ligamentum flavum and spread the drug into the epidural space. We confirmed the accuracy of this method using ultrasound with superb microvascular imaging (SMI) to visualize the epidural space. Here, we report two cases of 63-year-old and 90-year-old males. The 63-year-old patient presented with severe pain in his right buttock that extended to the posterior lower leg. The 90-year-old patient presented with intermittent claudication every 10 min. LFRM was performed, and SMI was used to confirm that the parenteral solution had spread into the epidural space. Our results indicate that LFRM can be used for interlaminar lumbar epidural steroid injections.
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Affiliation(s)
- Manabu Maeda
- Department of Orthopedics, Maeda Orthopaedic Clinic, Nara 630-8306, Japan
- Correspondence: ; Tel.: +81-742-24-5595
| | - Nana Maeda
- Department of Orthopedics, Maeda Orthopaedic Clinic, Nara 630-8306, Japan
| | - Keisuke Masuda
- Department of Orthopedics, Higashiosaka Medical Center, Osaka 578-8588, Japan
| | - Yoshiyuki Kamatani
- Department of Orthopedics, Saiseikai Nara Hospital, Nara 630-8145, Japan
| | - Shimizu Takamasa
- Department of Orthopedics, Nara Medical University, Nara 634-8521, Japan
| | - Yasuhito Tanaka
- Department of Orthopedics, Nara Medical University, Nara 634-8521, Japan
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Joshi J, Roytman M, Aiyer R, Mauer E, Chazen JL. Cervical spine ligamentum flavum gaps: MR characterisation and implications for interlaminar epidural injection therapy. Reg Anesth Pain Med 2022; 47:459-463. [DOI: 10.1136/rapm-2022-103552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/01/2022] [Indexed: 11/04/2022]
Abstract
BackgroundCervical epidural steroid injections are commonly performed to manage pain from cervical spine disease. Cadaveric studies have demonstrated incomplete ligamentum flavum fusion in the central interlaminar region with resultant midline gaps. We performed an MR-based characterization of cervical ligamentum flavum midline gaps to improve understanding of their prevalence and guide interventionalists in procedural planning.MethodsFifty patients were retrospectively reviewed following institutional review board approval. Axial T2-weighted spinecho sequences were used to evaluate ligamentum flavum integrity at the interlaminar spaces of C5–C6, C6–C7 and C7–T1. Interlaminar spaces were further subdivided into superior, middle, and inferior portions, yielding 150 interlaminar regions characterized from C5 to T1. Subsequently, a novel categorization of gap morphology was performed, highlighting gap morphology (anterior, posterior, full, or no gap).ResultsFull gaps of the ligamentum flavum, with direct epidural space exposure, were observed with variable prevalence at all three levels evaluated. The highest incidence of full ligamentum flavum gaps were observed at C7–T1, occurring in 71.4% of patients at both its middle and inferior portions. The inferior aspect of C5–C6 demonstrated the lowest observed rates of full ligamentum flavum gap (2%).ConclusionsLigamentum flavum gaps occur in the lower cervical spine at high rates, with the highest prevalence of full thickness ligamentum flavum gaps at C7–T1. Interventionists must be aware of these important normal variants and evaluate preprocedural MRI to plan interventions.
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Um MK, Lee E, Lee JW, Kang Y, Ahn JM, Kang HS. Fluoroscopic lumbar transforaminal epidural steroid injections for recurrent herniated intervertebral disc after discectomy: Effectiveness and outcome predictors. PLoS One 2022; 17:e0271054. [PMID: 35797391 PMCID: PMC9262237 DOI: 10.1371/journal.pone.0271054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 06/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Despite transforaminal epidural steroid injection (ESI) being the first choice in patient with recurrent herniated intervertebral disc (HIVD), efficacy of ESI in those patients are not well established. Herein, we evaluate the effectiveness and outcome predictors of fluoroscopic transforaminal ESI for recurrent HIVD. Methods Seventy-seven patients (48 male; mean age, 51.3 years) with recurrent lumbar HIVD were included and divided into three groups according to initial treatment: conservative treatment, transforaminal ESI, and immediate surgery. ESI effectiveness was evaluated by operation rates, injection numbers in 6 months, and pain reduction (visual analog scale (VAS) scores). Clinical and MRI variables were analyzed as possible outcome predictors. Each subject in the transforaminal ESI group was individually matched to two patients with initial HIVD (control group). Results In the transforaminal ESI group (n = 37), 20 patients (54.1%) did not undergo reoperation. The initial and follow-up VAS scores were significantly higher in the reoperation group (p = 0.014, p = 0.019, respectively). Patients with either paresthesia or motor weakness (12/19, 63.2%) had a significantly higher reoperation rate than patients with only pain (5/18, 27.8%; p = 0.031). Extruded disc ratios ≥2.0 were significantly higher in the reoperation group (10/17, 58.8%; p = 0.048). The reoperation rate in the transforaminal ESI group (17/37, 45.9%) was higher than the operation rate in the control group (6/73, 8.2%; p<0.001). Conclusion Transforaminal ESI was effective in reducing radicular pain in patients with recurrent HIVD. Approximately 54% of patients did not undergo reoperation. An extruded disc ratio ≥2.0 and paresthesia or motor weakness were poor outcome predictors.
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Affiliation(s)
- Mi-Kyung Um
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- Department of Radiology, Kangwon National University School of Medicine, Chuncheon-si, Republic of Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- * E-mail:
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Joong Mo Ahn
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
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Image Segmentation-Based Cervical Spine MRI Images to Evaluate the Treatment of Patients with Chronic Pain. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2648659. [PMID: 35799646 PMCID: PMC9256301 DOI: 10.1155/2022/2648659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022]
Abstract
The objective of this research was to investigate the application effect of cervical spine magnetic resonance imaging (MRI) image segmentation algorithm guidance in the treatment of chronic pain with cervical epidural puncture. A total of 72 patients with chronic pain were selected and divided into a cervical spine MRI image-guided group (group A) and a blind puncture group with traditional experience (group B). The results showed that the puncture time of group A was
(min), while that of group B was
(min), so the puncture time of patients in group A was significantly shorter than that of group B (
). The incidences of pain at the puncture site of patients in group A and group B were 6% and 10%, respectively. The incidence of pain at the puncture site in group A was significantly lower than that in group B (
). The success rate of the first puncture in group A was 78%, and that in group B was 54%. The success rate of the first puncture in group A was significantly higher than that in group B (
). The complication rate of group A was 22.22%, and that of group B was 80.56%. The incidence of complications in group A was significantly lower than that in group B (
). In addition, there was no significant difference in the puncture depth between the two groups (
). In summary, the guidance of cervical spine MRI image segmentation algorithm can reduce the time and times of puncture and improve the success rate of puncture, thereby reducing the incidence of postoperative complications.
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CT-guided transforaminal epidural steroid injection for discogenic lumbar radiculopathy: influence of contrast dispersion and radiologist's experience on clinical outcome. Skeletal Radiol 2022; 51:783-793. [PMID: 34382098 PMCID: PMC8854304 DOI: 10.1007/s00256-021-03881-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/15/2021] [Accepted: 07/25/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the impact of contrast dispersion pattern/location during lumbar CT-guided transforaminal epidural steroid injection (TFESI) and experience of the performing radiologist on therapeutic outcome. MATERIALS AND METHODS In this single-center retrospective cohort study, two observers analyzed contrast dispersion during CT-guided TFESI of 204 patients (age 61.1 ± 14 years) with discogenic unilateral single-level L4 or L5 radiculopathy. The contrast dispersion pattern was classified as "focal," "linear," or "tram-track"; the location was divided into "extraforaminal," "foraminal," or "recessal." Pain was assessed before and 4 weeks after treatment using a numerical rating scale (0, no pain; 10, intolerable pain). Additionally, the patient global impression of change (PGIC) was assessed. The TFESI was performed by musculoskeletal radiologists (experience range: first year of musculoskeletal fellowship training to 19 years). Contrast pattern/location and radiologist's experience were compared between "good responder" (≥ 50% pain reduction) and "poor responder" (< 50%). A p-value < 0.05 was considered to be statistically significant. RESULTS Overall, CT-guided TFESI resulted in a substantial pain reduction in 46.6% of patients with discogenic radiculopathy. The contrast dispersion pattern and location had no effect on pain relief (p = 0.75 and p = 0.09) and PGIC (p = 0.70 and p = 0.21) 4 weeks after TFESI. Additionally, the experience of the radiologist had no influence on pain reduction (p = 0.92) or PGIC (p = 0.75). Regarding pre-interventional imaging findings, both the location and grading of nerve compression had no effect on pain relief (p = 0.91 and p = 0.85) and PGIC (p = 0.18 and p = 0.31). CONCLUSION Our results indicate that neither contrast agent dispersion/location nor the experience of the radiologist allows predicting the therapeutic outcome 4 weeks after the procedure.
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Kim BR, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Effectiveness of epidural steroid injection in patients with lumbar herniated intervertebral disc under a "wait-and-see" policy. Acta Radiol 2022; 63:67-75. [PMID: 33435714 DOI: 10.1177/0284185120985500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are no consensus and guidelines on the optimal interval of repeat epidural steroid injections (ESI) for patients with lumbar herniated intervertebral disc (HIVD) who respond to initial ESI. PURPOSE To evaluate the effectiveness of ESI in patients with HIVD under a "wait-and-see" policy, i.e. as-needed injections not on a predetermined schedule. MATERIAL AND METHODS A total of 592 patients with lumbar HIVD received spine injections between January and December 2017. After excluding patients with excellent (no pain) or poor (>70% residual symptoms) response in the two- or three-week pain assessment, the data of 141 responders were analyzed (60 men, 73 women; age = 50.55±17.25 years). We divided patients into wait-and-see (n=124) and early repeat-ESI (n=17) groups, who received repeat ESIs within three weeks. Evaluations of characteristics and outcomes were performed with the chi-square test or independent Student's t-test. RESULTS Six patients (4.8%) in the wait-and-see group and 1 (5.9%) in the early repeat-ESI group underwent operation within one year (P=0.85). A mean of 1.52±0.82 ESIs was performed in the wait-and-see and a mean of 2.29±0.47 ESIs in the early repeat-ESI group over one year (P<0.001). The time interval between the first and second ESIs was longer in the wait-and-see group than in the early repeat-ESI group (97.15 vs. 15.47 days, P<0.001). Seventy-eight patients (62.9%) in the wait-and-see group could control their pain with a single ESI. CONCLUSION A "wait-and-see" policy could be an effective pain management option for patients with lumbar HIVD who respond to initial ESI.
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Affiliation(s)
- Bo Ram Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Joong Mo Ahn
- Department of Radiology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul, Republic of Korea
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Cervical Spondylopathy and Lumbar Intervertebral Disc Herniation Coexist in Free Radical Metabolism and Focus Separation in the Body. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:1480282. [PMID: 34873436 PMCID: PMC8643231 DOI: 10.1155/2021/1480282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/05/2021] [Accepted: 10/15/2021] [Indexed: 01/31/2023]
Abstract
Lumbar disc herniation is a common lumbar disease in clinics, which is related to improper use of lumbar vertebrae and osteoporosis. Surgical removal of nucleus pulposus and maintenance of lumbar structural stability are important for the treatment of lumbar disc herniation. At present, in clinical percutaneous intervertebral foramen endoscopic surgery for lumbar disc herniation, interlaminar and intervertebral foramen approaches can be selected. Different approaches have different degrees of difficulty in the treatment of lumbar disc herniation, and the clinical effects that may be obtained are different. In this study, we observed the influencing factors of plasma nitric oxide (NO) and free radical metabolism in patients with lumbar disc herniation and the correlation between the effects of focus separation. The organic combination of local and total illness differentiation and dialectics, conventional acupuncture, and electrical stimulation was highlighted in this study, which linked local acupoints squeezed by nerve roots with distant acupoints along meridians. The use of authoritative quantitative standards and a multifactor assessment of the disease can accurately represent the disease's severity. The patient's condition changes in each period may be expressed more accurately, thoroughly, and objectively through the rise or reduction of the score, making self-evaluation easier for the patient. Electroacupuncture at point may be one of the most important strategies to minimize free radical damage, based on changes in plasma levels.
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Bakrukov D, Siddique Z, Mangla R, Swarnkar A. Retrospective Comparative Analysis of Fluoroscopic-Guided Lumbar Puncture in the Routine Prone Versus Lateral Decubitus Position. Cureus 2021; 13:e18799. [PMID: 34804662 PMCID: PMC8594753 DOI: 10.7759/cureus.18799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 11/06/2022] Open
Abstract
Objective: We sought to investigate patient outcomes such as success rate, fluoroscopy time, and radiation dose for fluoroscopic-guided lumbar puncture procedures performed in the prone position versus the lateral decubitus (LD) position. Methods: Retrospective chart analysis was performed at a single institution from 2013 to 2019. Cases were separated by performance in the prone or lateral decubitus positions. Data collected include patient characteristics, fluoroscopy time, radiation dose (DAP), puncture level, indication, opening pressure, and success rate. Exclusion criteria include trainee participation and procedures where positioning was unspecified. Mean fluoroscopy time, DAP, and procedure success rate were calculated and compared between groups. Results: Mean fluoroscopy time (min) was 0.97 and 1.07 in the LD and prone groups respectively (p = 0.21). Mean DAP (mGy) was 43.18 and 42.06 in the LD and prone groups respectively (p = 0.38). Success rate was 98.3% and 89.1% in the LD and prone groups respectively (p = 0.04). Room time (minutes) was 64.46 and 77.77 in the LD and prone groups respectively (p = 0.04). Conclusion: Our study found no statistically significant difference in terms of fluoroscopic time or radiation dose when comparing fluoroscopic-guided lumbar punctures in the prone versus lateral decubitus positions. Further analysis did show a statistically significant increased success rate and a shorter room time for the lateral decubitus position.
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Affiliation(s)
- Dmitriy Bakrukov
- Radiology, State University of New York Upstate Medical University, Syracuse, USA
| | - Zaid Siddique
- Radiology, State University of New York Upstate Medical University, Syracuse, USA
| | - Rajiv Mangla
- Neuroradiology, State University of New York Upstate Medical University, Syracuse, USA
| | - Amar Swarnkar
- Neuroradiology, State University of New York Upstate Medical University, Syracuse, USA
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15
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The Pain Crisis: Interventional Radiology's Role in Pain Management. AJR Am J Roentgenol 2021; 217:676-690. [DOI: 10.2214/ajr.20.24265] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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A common yet undescribed MRI finding in newborns: posterior epidural space edema of the cervical and upper thoracic spine. Neuroradiology 2021; 64:371-379. [PMID: 34409502 DOI: 10.1007/s00234-021-02786-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Posterior spinal epidural space (PSES) is a fat-containing space. We noted numerous spinal MRIs demonstrating T2-hyperintense thickening of the cervical/thoracic PSES in early newborns, resembling epidural edema. Our aim is to describe the appearance/frequency of this finding and explore any associations with delivery. METHODS Retrospectively, 202 spinal/cranial MRIs, belonging to newborns within the first 2 weeks of life, were evaluated using sagittal fat-suppressed T2, T1-FLAIR, and STIR. Exclusion criteria were motion, incomplete spine imaging, lack of sagittal T2/STIR, and inadequate clinical data. Ninety-three patients were included in the final analysis. We reviewed all cases for T2 hyperintense thickened PSES and, if present, accompanying abnormal T1 signal. The spinal canal and PSES thickness were measured. Clinical and demographic data were collected. Follow-up exams were evaluated, if available. Cases with thickened PSES and without were compared. RESULTS T2-hyperintense thickened PSES was present in 60/93 (64.5%). Mean PSES thickness was 2.3 mm (0.7-4.6). The mean PSES thickness/spinal canal diameter ratio was 0.2 (0.1-0.5). No cord compression was identified. One had a hyperintense T1 PSES signal, compatible with epidural hemorrhage. No difference was found between those with thickened PSES and without, regarding sex, gestational age, birth weight, birth method, difficult delivery, fetal position, or neurologic status (p>0.05). Follow-up imaging was available in 10, with complete resolution of T2 hyperintense PSES thickening. CONCLUSION T2 hyperintense PSES thickening is common in imaged newborns and reversible at follow-up. No significant neurologic outcomes were found related to its presence; thus, follow-up does not appear necessary.
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Elashmawy MA, Shaat RM, Abdelkhalek AM, El Boghdady E. Caudal epidural steroid injection ultrasound-guided versus fluoroscopy-guided in treatment of refractory lumbar disc prolapse with radiculopathy. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00388-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractBackgroundLumbar disc prolapse is a localized herniation of disc beyond intervertebral disc space and is the most common cause of sciatica; the aim of this study is to investigate the efficacy of ultrasound (US)-guided caudal epidural steroid injection (CESI) compared with fluoroscopy (FL)-guided CESI in treatment of patients with refractory lumbar disc prolapse (LDP) with radiculopathy.ResultsAt the beginning of the study, there was no significant difference between both groups in all parameters. (a) Group 1 had significantly improved the straight leg raising and modified Schober tests, VAS, and ODI at 1-month and 3-month post-injection evaluation in comparison to baseline recordings (p< 0.001); (b) Group 2 had significantly improved the straight leg raising and modified Schober tests, VAS, and ODI at 1-month and 3-month post-injection evaluation in comparison to baseline recordings (p< 0.001); and (c) US-guided CESI was not statistically different from the FL-guided CESI in the improvement of the straight leg raising (p= 0.87, 0.82) and modified Schober tests (p= 0.87, 0.82) as well as VAS (p= 0.40, 0.43) and ODI (p= 0.7, 0.2) at 1-month and 3-month post-injection evaluation. In a multivariate analysis using CI = 95%, the significant predictors for a successful outcome were duration<6 months (p= 0.03, OR = 2.25), target level not L2-3/L3-4 (p< 0.001, OR = 4.13), and LDP other than foraminal type (p= 0.002, OR = 3.78). However, age < 40 years was found to be non-significant in predicting a successful outcome (p= 0.38, OR = 0.98).ConclusionUS is excellent in guiding CESI with similar treatment outcomes as compared with FL-guided CESI.Trial registrationClinicalTrials.gov Identifier:NCT03933150.
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18
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Fluoroscopy-guided spine injections: establishing a successful service in your radiology department or practice. Skeletal Radiol 2020; 49:475-479. [PMID: 31620831 DOI: 10.1007/s00256-019-03319-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/05/2019] [Accepted: 09/20/2019] [Indexed: 02/02/2023]
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19
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Bise S, Dallaudiere B, Pesquer L, Pedram M, Meyer P, Antoun MB, Hocquelet A, Silvestre A. Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain. Eur Radiol 2020; 30:3152-3160. [DOI: 10.1007/s00330-020-06733-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 01/27/2020] [Accepted: 02/07/2020] [Indexed: 12/24/2022]
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20
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Marcia S, Zini C, Bellini M. Image-Guided Percutaneous Treatment of Lumbar Stenosis and Disc Degeneration. Neuroimaging Clin N Am 2019; 29:563-580. [PMID: 31677731 DOI: 10.1016/j.nic.2019.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Low back pain, radicular leg pain, and lumbar spinal stenosis are the most common of all chronic pain disorders. Discogenic pain is related to distress of annular fibers and tears, whereas spinal stenosis is related to reduction of the spinal canal dimensions and compression of the neural elements; radicular pain is mainly related to disc herniation and is initially managed conservatively. The percutaneous minimally invasive approach in discogenic and radicular pain is designed to reduce the volume of the nucleus pulposus in patients with failure of medical and physical treatment prolonged for at least 6 weeks.
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Affiliation(s)
- Stefano Marcia
- Ahead Diagnostic and Interventional Radiology Unit, Hospital "Santissima Trinità", ATS Sardegna ASSL, Cagliari, Italy.
| | - Chiara Zini
- UOC Neuroimmagini e Neurointerventistica, Dipartimento di Scienze Neurologiche e Motorie, Azienda Ospedaliera Universitaria Senese, via Bracci 16, 53100 Siena, Italy
| | - Matteo Bellini
- UOC Neuroimmagini e Neurointerventistica, Dipartimento di Scienze Neurologiche e Motorie, Azienda Ospedaliera Universitaria Senese, via Bracci 16, 53100 Siena, Italy
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22
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Clinical and imaging characteristics of patients with extreme low back pain or sciatica referred for spinal injection. Neuroradiology 2019; 61:881-889. [PMID: 31101947 DOI: 10.1007/s00234-019-02222-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 05/06/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To analyze the causes of pain, imaging characteristics, and therapeutic effect of spinal injection in patients with extreme low back pain or sciatica. METHODS We analyzed 381 consecutive patients with extreme low back pain or sciatica visiting our spinal intervention center between January and December 2017. Clinical and imaging characteristics were analyzed. The treatment response, defined as a numerical pain rating scale decrease of ≥ 30%, was measured. Fisher's exact test was performed to identify the association between the injection response and subsequent lumbar surgery rate. RESULTS The most frequent cause of pain was spinal stenosis, followed by herniated intervertebral disc, facet osteoarthritis, and osteoporotic compression fracture. A herniated intervertebral disc was the most common disorder in patients < 50 years of age, while spinal stenosis was the most common in patients ≥ 50 years of age. Women comprised 66.4% of the study population. The majority of lumbar pathologies occurred below L3/4. Spinal injection was found to be effective in 44.2% of cases. Those who responded to the injection showed a significantly lower rate of lumbar surgery within 6 months (P = 0.004). CONCLUSIONS Those with extreme low back pain or sciatica had clinical and imaging characteristics similar to those with typical low back pain referred for spinal injection. Spinal injection could be an effective method of pain control for patients with extreme low back pain or sciatica.
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Abstract
One of the most important goals of palliative medicine and hospice care is pain relief. Although great strides have been made in veterinary analgesia, severe pain, especially at home, is still difficult to control. Pain control in the context of palliative medicine and hospice care is far more advanced in human medicine. Many modalities used in chronically or terminally ill humans might be adapted to animals to better manage severe pain. This article discusses drugs and procedures used to control pain in humans that are relatively nascent or unavailable in veterinary medicine and deserve further attention.
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Affiliation(s)
- Jordyn M Boesch
- Section of Anesthesiology and Pain Medicine, Department of Clinical Sciences, Cornell University Hospital for Animals, Cornell University College of Veterinary Medicine, 930 Campus Road, Box 32, Ithaca, NY 14853, USA.
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Paliwal B, Sharma RS, Bhatia P, Kamal M. Fluoroscopic guided epidural anaesthesia: A rescuing skill in difficult anaesthetic management. Indian J Anaesth 2019; 63:679-680. [PMID: 31462820 PMCID: PMC6691642 DOI: 10.4103/ija.ija_268_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bharat Paliwal
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ravi S Sharma
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pradeep Bhatia
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Manoj Kamal
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Ozsoy-Unubol T, Ercalik T, Gunduz OH. Comparison of Epidural Steroid Injection Efficiency with Two Different Doses in Radiculopathies Associated with Lumbar Disc Herniation. World Neurosurg 2018; 124:S1878-8750(18)32879-1. [PMID: 30590213 DOI: 10.1016/j.wneu.2018.12.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Transforaminal epidural steroid injections (TFESIs) have been increasingly used in the treatment of lumbar radicular pain resistant to conservative modalities. Although different steroids can be used at different doses, the minimally effective steroid dose should be used to reduce side effects. The present retrospective study examined and compared the efficacy of 40 mg and 80 mg of methylprednisolone in TFESIs. METHODS We included 67 patients who had undergone unilateral L5-S1 TFESIs under fluoroscopic guidance in the present study. Assessments were conducted at baseline and at 1 hour, 3 weeks, and 3 months after the TFESIs. The Short-Form 36-item Health Survey, Numeric Rating Scale, Oswestry Disability Index, and Istanbul Low Back Pain Disability Index were used as outcome measures. RESULTS The present study evaluated 33 patients who had undergone TFESIs with 40 mg of methylprednisolone and 34 patients who had undergone TFESIs with 80 mg of methylprednisolone. Although no statistically significant differences were found between the 2 groups' outcome measures, both groups showed significant improvements in pain, disability, and quality of life at 3 weeks and 3 months after treatment. CONCLUSIONS TFESIs with 40 mg and 80 mg are effective for the treatment of pain that results from lumbar disc herniation. They also positively affect patients' disability and quality of life. However, neither steroid dose was more efficient than the other dose. Therefore, we believe the smaller dose should be preferred to reduce the potential side effects of steroids.
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Affiliation(s)
- Tugba Ozsoy-Unubol
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey.
| | - Tulay Ercalik
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey; Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey; Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, Marmara University School of Medicine, Istanbul, Turkey
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26
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Marcia S, Zini C, Hirsch JA, Chandra RV, Bellini M. Steroids Spinal Injections. Semin Intervent Radiol 2018; 35:290-298. [PMID: 30402012 DOI: 10.1055/s-0038-1673421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Spinal pain is a common condition leading to significant disability and high cost. Spinal injections have been demonstrated to be effective short-term treatments with cost-utility superior to numerous other treatments, including surgical procedures. Appropriate patient selection-based on clinical and imaging finding-and the use of image guidance associated with technical precautions improve the safety and effectiveness of spinal injection and overall patient outcomes.
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Affiliation(s)
- Stefano Marcia
- Chief of Diagnostic and Interventional Radiology, Ospedale "Santissima Trinità", Cagliari, Italy
| | - Chiara Zini
- Department of Radiology, Ospedale "Santa Maria Annunziata", Azienda Ospedaliera Toscana Centro, Firenze, Italy
| | - Joshua A Hirsch
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Ronil V Chandra
- Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Melbourne, Australia.,Chief of Stroke Imaging and Endovascular Clot Retrieval, Monash Imaging, Monash Health, Melbourne, Australia.,Neurovascular Surgery, Monash Health, Melbourne, Australia.,Chief of Neurovascular Imaging Research, Monash Health, Melbourne, Australia.,Departments of Surgery and Medicine, Monash Health, Melbourne, Australia
| | - Matteo Bellini
- Chief of Minimal Invasive Spinal Treatment Unit.,Neuroimaging and Neurointerventional Unit.,Department of Neurological and Neurosensorial Sciences.,Ospedale "Santa Maria alle Scotte", Azienda Ospedaliera Universitaria Senese, Siena, Italy
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27
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Nascene DR, Ozutemiz C, Estby H, McKinney AM, Rykken JB. Transforaminal Lumbar Puncture: An Alternative Technique in Patients with Challenging Access. AJNR Am J Neuroradiol 2018; 39:986-991. [PMID: 29567652 DOI: 10.3174/ajnr.a5596] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 01/24/2018] [Indexed: 12/17/2022]
Abstract
Interlaminar lumbar puncture and cervical puncture may not be ideal in all circumstances. Recently, we have used a transforaminal approach in selected situations. Between May 2016 and December 2017, twenty-six transforaminal lumbar punctures were performed in 9 patients (25 CT-guided, 1 fluoroscopy-guided). Seven had spinal muscular atrophy and were referred for intrathecal nusinersen administration. In 2, CT myelography was performed via transforaminal lumbar puncture. The lumbar posterior elements were completely fused in 8, and there was an overlying abscess in 1. The L1-2 level was used in 2; the L2-3 level, in 10; the L3-4 level, in 12; and the L4-5 level, in 2 procedures. Post-lumbar puncture headache was observed on 4 occasions, which resolved without blood patching. One patient felt heat and pain at the injection site that resolved spontaneously within hours. One patient had radicular pain that resolved with conservative treatment. Transforaminal lumbar puncture may become an effective alternative to classic interlaminar lumbar puncture or cervical puncture.
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Affiliation(s)
- D R Nascene
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - C Ozutemiz
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - H Estby
- University of Minnesota Medical School (H.E.), Minneapolis, Minnesota
| | - A M McKinney
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - J B Rykken
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
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Abstract
The identification of epidural space with loss of resistance (LOR) is commonly performed. But it lacks specificity. Epidural pressure waveform analysis (EPWA) provides a simple confirmative adjunct for LOR. If the needle is located within the epidural space, measurement of the pressure at its tips shows a pulsatile waveform. Previous studies demonstrated satisfactory sensitivity and specificity of EPWA. However, success or failure of epidural injection was confirmed by the pinprick test, which is limited for patients in the setting of the pain clinic. In this study, we evaluated the sensitivity, specificity, as well as positive and negative predictive values of EPWA for cervical epidural steroid injection (CESI) confirmed by fluoroscopy.One hundred and five CESIs of 75 patients suffering from neck and radicular arm pain of over 3 months duration were enrolled. The physician injected 5 mL of normal saline after a feeling of satisfactory LOR. Saline filled extension tubing, connected to a pressure transducer, was attached to the needle. A 3 mL bolus of contrast medium was injected to confirm the success of CESI.The incorrect identification of epidural space with LOR (false LOR) was 29.5%. Of these 31 failed CESIs, 2 showed epidural waveform and 29 did not. The sensitivity, specificity, positive and negative predictive value of EPWA was 94.5%, 93.5%, 97.2%, and 87.7%, respectively.EPWA shows satisfactory reliability and is a simple adjunct to decrease false LOR for CESI. Further confirmative studies are required before its routine use in clinical practice.
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Affiliation(s)
- Ji H. Hong
- Department of Anesthesiology and Pain Medicine
| | - Sung W. Jung
- Department of Psychiatry, Keimyung University DongSan Hospital, DaeGu, Korea
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Effectiveness of a multimodal pain management concept for patients with cervical radiculopathy with focus on cervical epidural injections. Sci Rep 2017; 7:7866. [PMID: 28801567 PMCID: PMC5554143 DOI: 10.1038/s41598-017-08350-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/06/2017] [Indexed: 12/31/2022] Open
Abstract
Cervical radiculopathy has become an increasing problem worldwide. Conservative treatment options have been recommended in many reviews on cervical radiculopathy, ranging from different types of physiotherapy to waiting for remission by natural history. No multimodal pain management concept (MPM) on an inpatient basis has been evaluated. This study aimed at showing the positive short-term effects of an inpatient multimodal pain management concept with focus on cervical translaminar epidural steroid injection for patients with cervical radiculopathy. 54 patients who had undergone inpatient MPM for 10 days were evaluated before and after 10-days treatment. The NRS (0-10) value for arm pain could be reduced from 6.0 (IQR 5.7-6.8) to 2.25 (IQR 2.0-3.1) and from 5.9 (IQR 4.8-6.0) to 2.0 (IQR 1.7-2.6) for neck pain. Neck pain was reduced by 57.4% and arm pain by 62.5%. 2 days after epidural steroid injection, pain was reduced by 40.1% in the neck and by 43.4% in the arms. MPM seems to be an efficient short-term approach to treating cervical radiculopathy. Cervical translaminar epidural steroid injection is an important part of this concept. In the absence of a clear indication for surgery, MPM represents a treatment option.
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