Comparison of Clinical Efficacy of Transforaminal and Interlaminar Epidural Steroid Injection in Radicular Pain due to Cervical Diseases: A Systematic Review and Meta-analysis

BACKGROUND

Cervical epidural steroid injection (ESI) has been used to alleviate axial or radicular pain incurred from various cervical pathologies, including herniated intervertebral disc (HIVD) and spinal stenosis (SS). However, the superiority of the transforaminal ESI (TFESI) method over the interlaminar ESI (ILESI) in terms of clinical effectiveness for the radicular pain is still controversial.

OBJECTIVES

This study has compared TFESI and ILESI in terms of clinical effectiveness, such as pain control and functional improvement, as well as the incidence of adverse events in patients with radicular pain secondary to cervical HIVD or SS.

STUDY DESIGN

A systematic review and meta-analysis.

SETTING

Primary clinic and tertiary referral center.

METHODS

A literature search was performed using Medline (PubMed), Embase, Cochrane Review, and KoreaMed databases from the studies published until March 2022. After reviewing titles, abstracts, and full texts of 371 studies during the initial database search, 6 studies were included in a qualitative and quantitative synthesis. Data, including pain score, functional score, and adverse events were extracted from 6 studies and were analyzed using a random-effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the Grading of Recommendations Assessment, Development and Evaluation methodology.

RESULTS

Among 6 studies, including 4 randomized controlled trials (RCTs), only 1 RCT showed that TFESI achieved a significant lower Numeric Rating Scale (NRS-11) at 1 month than ILESI, but no advantage in the NRS-11 at 3 months and the Neck Disability Index at 1 month and 3 months, respectively. Another RCT indicated that ILESI achieved significantly more neck NRS-11 reduction at 1 month and 3 months than TFESI. The other 4 studies revealed no significant difference between the 2 groups. A meta-analysis showed no significance in clinical outcomes, except that ultrasound-guided TFESI featured less intravascular leakage of contrast than ILESI. The level of evidence was low because of inconsistency and imprecision.

LIMITATIONS

The feasible clinical heterogeneity from the relatively small number of patients included as well as differences in methodology across the studies.

CONCLUSIONS

Comprehensive reviews of selected articles revealed TFESI could not be recommended over ILESI for the sake of a preferential cervical radiculopathy control due to the weak evidential strength.

Awake, Transforaminal Endoscopic Lumbar Decompression Surgery to Treat L5-S1 Adjacent Segment Disease: A Case Series

BACKGROUND

Lumbar radiculopathy secondary to L5-S1 degenerative changes adjacent to a lumbar fusion usually requires extending the fusion to include the degenerative L5-S1 level; this revision surgery can often be a very invasive procedure.

OBJECTIVE

To describe outcomes of awake, transforaminal endoscopic decompression surgery for patients presenting with lumbar radiculopathy as a result of L5-S1 degenerative disc disease below lumbar fusions.

STUDY DESIGN

Retrospective chart review.

METHODS

Awake, endoscopic decompression surgery was performed in 538 patients over a 5-year period from 2014 through 2019 by a single surgeon at a single institution.  The records of 18 consecutive patients who underwent transforaminal lumbar endoscopic decompression surgery to treat radiculopathy secondary to L5-S1 adjacent segment disease were retrospectively reviewed. All included patients were followed for at least 2 years after surgery. All patients were treated at L5-S1 and had fusion constructs that ended at L5.

RESULTS

Thirteen men and 5 women patients ranging in age from 38 to 83 (average age of 68.9 ± 11.5) were treated for symptomatic adjacent segment disease at L5-S1 during the 5-year time period. Surgery was successful in all cases, except 2 patients (11%) at 2 years follow-up had recurrent symptomatic pathology at L5-S1 and required additional surgical treatment. The average preoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were 7.5(± 1.3) and 45.3 (± 12.3) respectively. The average 2-year postoperative VAS and ODI scores were 2.4 (± 1.5) and 22.5 (± 9.6) respectively, excluding the 2 patients with recurrent pathology. The average body mass index (BMI) and L5-S1 disc height in the 2-year successful group (n = 16) were 30.6 (± 7.4) and 8.7 mm (± 3.5 mm) respectively; the average BMI and L5-S1 disc height in the 2-year failure group (n = 2) were 25.8 (± 5.9) and 7.9 (± 2.6) respectively.

LIMITATIONS

This was a retrospective case series.

CONCLUSIONS

Endoscopic spine surgery offers patients with fusions that terminate at L5 a safe and effective option for treatment of lumbar degenerative spine disease at L5-S1 below their fusion constructs. A longer follow-up and a larger prospective study would be necessary to consider the utility of endoscopic compression versus extending the fusion construct.

Foraminal Access Strategies in Patients with Lumbar Posterolateral Fusions in Transforaminal Endoscopic Spine Surgery: Case Series and Technical Note

BACKGROUND

The treatment of post-laminectomy lumbar radiculopathy in the setting of a large posterolateral fusion mass presents an anatomic challenge to the spine interventionalist.

OBJECTIVE

To describe outcomes of awake, transforaminal endoscopic surgical treatment for patients presenting with lumbar radiculopathy after instrumented posterolateral lumbar fusions.

STUDY DESIGN

Retrospective chart review.

SETTING

This study took place in a single-center, academic hospital.

METHODS

The records of 538 patients who underwent awake transforaminal lumbar endoscopic decompression surgery performed by a single surgeon at a single institution between 2014 and 2019 were retrospectively reviewed. Fifteen consecutive patients who required drilling through their posterolateral fusion masses to access the post-fusion foraminal stenosis were included in this study. All included patients were followed for at least one year after surgery.

RESULTS

Fifteen patients (7 male and 8 female) with an average age of 68.1 years (range 38-89, standard deviation 13.4 years) underwent awake transforaminal foraminal decompression surgeries that utilized special techniques to drill through large posterolateral fusion masses to access their foraminal stenosis. One patient (7%) required repeat surgery in the postoperative period due to lack of surgical improvement. For the remaining 14 patients, at one year follow up, the preoperative visual analog scale (VAS) for leg pain and Oswestry disability index (ODI) improved from 7.0 (± 1.7) and 40.7% (± 12.9) to 1.7 (± 1.6) and 12.1% (± 11.3). There were no complications such as infection, durotomy, or neurologic injury.

LIMITATIONS

Retrospective case series.

CONCLUSION

Transforaminal endoscopic spine surgery offers a unique approach to post-laminectomy and post-fusion foraminal compression because it avoids scar tissue resulting from previous posterior approaches. Large posterolateral fusion masses associated with some posterior fusions can be a sizeable bony barrier to transforaminal access. The authors share their techniques and success for navigating large posterior, bony fusion masses in transforaminal post-fusion foraminal decompression.

Comparison of Caudal Versus Transforaminal Epidural Steroid Injection in Post Lumbar Surgery Syndrome After Single-level Discectomy: A Prospective, Randomized Trial

BACKGROUND

Epidural fibrosis (EF) is one of the leading causes of post lumbar surgery syndrome (PLSS). Although there are studies in the literature suggesting that lumbar epidural steroid injections are an effective method in the pain management of PLSS caused by EF, no study is available comparing the effectiveness and safety of caudal and transforaminal approaches.

OBJECTIVES

To investigate the efficacy of caudal epidural steroid injection (CESI) versus transforaminal epidural steroid injection (TFESI) in patients with PLSS.

STUDY DESIGN

A prospective, randomized, assessor-blind study.

SETTING

Interventional pain management center at a tertiary care center.

METHODS

Patients with low back and radicular pain related to EF following single-level lumbar discectomy were included. The patients were randomly divided into 2 groups: a CESI group and a TFESI group. All patients were assessed before the procedure (baseline) and at one hour, 3 weeks, and 3 months after the procedure using the Numeric Rating Scale (NRS-11) and at baseline, 3 weeks, and 3 months using the modified Oswestry Disability Index (mODI). Treatment success was defined as a >= 50% decrease in the NRS-11 scores compared to baseline.

RESULTS

A total of 56 patients (n = 26 CESI group; n = 30 TFESI group) were included. NRS-11 and mODI scores showed a significant decline in both groups at all follow-ups (P < 0.001). At 3 weeks, the improvement in the mODI scores was significantly higher in the TFESI group (P = 0.020). In all follow-ups, the NRS-11 scores were similar between the groups. At 3 weeks, the rates of patients with a >= 50% decrease in NRS-11 scores were 53.8% and 60% in the CESI group and TFESI group, respectively, while these rates were 30% and 26.7%, respectively, at 3 months.

LIMITATIONS

This study had no placebo-control group and a relatively short follow-up.

CONCLUSION

Both CESI and TFESI are effective and safe methods in the treatment of PLSS caused by EF following lumbar discectomy. These methods can reduce pain and disability. Although both methods have similar treatment success rates, TFESI seems to be a more effective treatment method in reducing disability at 3-week follow-up.

Awake, Transforaminal Endoscopic Lumbar Spine Surgery in Octogenarians: Case Series

BACKGROUND

Optimal approaches for treating surgical spine pathology in very geriatric patients, such as those over the age of 80, remain unclear.

OBJECTIVE

To describe outcomes of awake, transforaminal endoscopic surgical treatment for patients 80 years old and older presenting with lumbar radiculopathy.

STUDY DESIGN

Retrospective case review.

METHODS

The records of 52 consecutive patients who underwent awake transforaminal lumbar endoscopic decompression surgery performed by a single surgeon at a single institution between 2014 and 2019 were retrospectively reviewed. All included patients were followed for at least one year after surgery.

RESULTS

Transforaminal surgeries performed were discectomies (21), foraminotomies (7), redo foraminotomies post-laminectomy (5), fusion explorations (13), facet cyst resections (3), spondylolisthesis decompressions (2), and a decompression for metastatic disease (1). Seven patients (13.5%) required repeat surgery at the treated level during the one-year follow-up. For the remaining 45 patients, at one-year follow-up, preoperative visual analog scale (VAS) for leg pain and Oswestry disability index (ODI) improved from 6.9 (± 1.4) and 40.5% (± 11.5) to 1.8 (± 1.4) and 12.0% (± 10.8), respectively. The only complication of the procedure was a single durotomy (2%).

LIMITATIONS

Single-center, retrospective case review with a relatively small number of cases with diverse clinical pathology. A multi-center case study with a larger number of patients with a more homogeneous case pathology would be more revealing.

CONCLUSIONS

Endoscopic spine surgery offers octogenarians a safe and effective option for the treatment of lumbar degenerative spine disease and may represent a valuable treatment strategy in a growing patient population.

Comparative Effectiveness of Parasagittal Interlaminar and Transforaminal Cervical Epidural Steroid Injection in Patients with Cervical Radicular Pain: A Randomized Clinical Trial

BACKGROUND

Cervical epidural steroid injections (ESI) are performed either by interlaminar (IL) or transforaminal (TF) approaches; however, there is controversy over which is better for safety and efficacy.

OBJECTIVES

This clinical trial aimed to compare the effectiveness of the parasagittal IL and TF approaches for cervical ESI in patients who were suffering from cervical radicular pain.

STUDY DESIGN

A prospective randomized assessor-blind study.

SETTING

The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea.

METHODS

This prospective randomized, assessor-blind trial included 80 patients with cervical radicular pain. We randomly assigned patients to the TF or parasagittal IL approach for cervical ESI. The effectiveness of the 2 groups was compared based on pain intensity using the Numeric Rating Scale (NRS-11) at 1 and 3 months. The Neck Disability Index (NDI), Medication Quantification Scale (MQS), and responders at 1 and 3 months between the 2 groups were compared.

RESULTS

The pain intensity of both groups significantly reduced after 1 and 3 months after each procedure (P < 0.001). Two-way repeated measures of analysis of variance showed no significant interaction between group and time for cervical radicular pain (P = 0.266), although NRS-11 pain score was lower in the TF group than the parasagittal IL group after 1 month (P = 0.010). NDI, MQS, and successful responders were not different between the 2 groups at 1 and 3 months after the procedure. We observed 7 cases (18.4%) of vascular visualization in the TF group, although no serious complications were found in either group.

LIMITATIONS

This study had no placebo control group and limited follow-up time.

CONCLUSIONS

Parasagittal IL ESI may be recommended over the TF ESI in reducing cervical radicular pain, considering both clinical effectiveness and safety.

Fully Endoscopic 360° Decompression Surgery for Thoracic Spinal Stenosis: Technical Note and Report of 8 Cases

BACKGROUND

Surgical options for treating thoracic spinal cord compression that results from circumferential stenosis typically involve instrumented fusion procedures. The authors present here an outpatient, awake, endoscopic surgical option for treating thoracic stenosis that avoids fusion.

OBJECTIVES

To evaluate the outcome and safety of combining fully endoscopic transforaminal and posterior approaches for ventral and dorsal decompression of thoracic spinal stenosis.

STUDY DESIGN

Retrospective case review.

SETTING

Single-center acute-care hospital.

METHODS

Eight patients with single-level, significant stenosis of the thoracic spinal canal were treated with fully endoscopic transforaminal and posterior approaches to achieve 360° ventral and dorsal decompression. Patients were followed up to 30 months postoperatively. Axial back pain was measured by the Visual Analog Scale (VAS) score, and paired Student t-test was used for statistical analysis.

RESULTS

Successful decompression was achieved in all 8 patients. All surgeries were performed as outpatient procedures under local anesthesia with intravenous (IV) sedation. There were no intraoperative dura tears, spinal cord or nerve root injury, postoperative infections, or cases of iatrogenic-induced segmental instability. All patients had significant improvement with VAS scores significantly lower postoperatively.

LIMITATIONS

Small case series evaluated retrospectively with 15-month average follow-up.

CONCLUSIONS

Combining fully endoscopic transforaminal and posterior approaches for both ventral and dorsal decompression under local anesthesia with IV sedation is an effective and safe minimally invasive surgical treatment for thoracic spinal stenosis.

Endoscopic Surgical Resection of the Retropulsed S1 Vertebral Endplate in L5-S1 Spondylolisthesis: Case Series

BACKGROUND

A severe grade I and grade II spondylolisthesis at L5-S1 creates an anatomic distortion that can compress the traversing S1 nerve with a retropulsed S1 vertebral body endplate and (sometimes) herniated disc.

OBJECTIVES

To evaluate the feasibility for awake, endoscopic treatment of symptomatic radiculopathy secondary to the deformity that results from the retropulsed superior endplate of S1 in grade I/II L5-S1 spondylolisthesis in patients with and without previous fusion surgery.

STUDY DESIGN

Retrospective chart review.

SETTING

This study took place in a single-center, academic hospital.

METHODS

In 325 patients over 4 years there were 19 patients (8 with previous L5-S1 fusions and 11 without) treated with transforaminal endoscopic spine surgery for decompression of the neural foramen at L5-S1 in the setting of spondylolisthesis (at least 5 mm) and a retropulsed superior vertebral endplate of S1.

RESULTS

The average preoperative Visual Analog Scale (VAS) back and leg scores were 6.1 and 6.7, and the average preoperative Oswestry Disability Index (ODI) score was 50.4. The average 1-year VAS back and leg scores were 2.2 and 2.2, and the average 1-year postoperative ODI score was 20.5. There was no statistically significant difference between the fusion and nonfusion groups. Patients treated were patients who presented with an S1 or L5 and S1 radiculopathy as their primary complaint and a L5-S1 spondylolisthesis of 5 mm or greater. Patients treated had no instability on flexion-extension x-rays. Eleven patients had not had fusions at L5-S1, and 8 patients had previous fusions at L5-S1 but still had a spondylolisthesis of at least 5 mm. The average slip for nonfusion patients was 8.4 mm, and the average slip for fusion patients was 8.8 mm. At 1-year follow-up the improvement in VAS back scores was 44% in the nonfusion group and 49% in the fusion group, and the improvement in VAS leg scores was 84% in the nonfusion group and 58% in the fusion group. At 1-year follow-up the improvement in ODI scores was 63% in the nonfusion group and 54% in the fusion group.

LIMITATIONS

Retrospective case series.

CONCLUSIONS

Awake, endoscopic surgery for the treatment of radiculopathy in the setting of a grade I/II L5-S1 spondylolisthesis is a viable minimally invasive treatment option for patients with radiculopathy in the setting of a stable L5-S1 spondylolisthesis with foraminal narrowing caused by a retropulsed superior endplate of the S1 vertebral body.

Four Complications Associated with Lateral and Oblique Fusion Treatable with Endoscopic Spine Surgery: Technical Note and Case Series

BACKGROUND

The lateral fusion procedure is a newer minimally invasive approach to indirectly decompressing and fusing a lumbar motion segment. As with many new procedures, new thoughtful approaches to recognizing and treating the complications of these procedures need to be developed.

OBJECTIVES

Here we describe our experience with transforaminal endoscopic decompression for complications of lateral and oblique lumbar fusion.

STUDY DESIGN

Retrospective case review.

SETTING

This was a multicenter study that took place in an academic hospital, community hospital, and ambulatory surgery center.

METHODS

An endoscopic treatment technique for 4 types of complications associated with lateral and oblique fusion is presented. We retrospectively reviewed cases at 3 centers in 2 countries of patients who underwent transforaminal endoscopic surgery for the treatment of lateral fusion complications in a 4-year period with a minimum follow-up of 1 year.

RESULTS

A preliminary series of 4 patients with an average age of 74.8 years (range, 69-82 years) who underwent transforaminal endoscopic procedures at the level of their lateral and oblique lumbar fusions between 2014 and 2018 is presented. Disc herniations, heterotopic bone formation, endplate fracture, and nerve root impingement by the interbody device were all treated endoscopically.

LIMITATIONS

Small case series evaluated retrospectively with 1-year follow-up.

CONCLUSIONS

Transforaminal endoscopic surgery is a useful minimally invasive surgical technique to treat several complications associated with lateral and oblique lumbar interbody fusion procedures.