Surgical techniques and perioperative surgical outcomes after discectomy for calcified lumbar disc herniation: a review and meta-analysis.

INTRODUCTION: Calcified lumbar disc herniation (CLDH) poses surgical challenges due to longstanding disease and adherence of herniated disc to the surrounding neural structures. The data regarding outcomes after surgery for CLDH are limited. This review was conducted to analyse the surgical techniques, perioperative findings and the postoperative clinical outcomes after surgery for CLDH. METHODS: PRISMA guidelines were followed whilst conducting this systematic review and meta-analysis. The literature review was conducted on 3 databases (PubMed, EMBASE, and CINAHL). After thorough screening of all search results, 9 studies were shortlisted from which data were extracted and statistical analysis was done. Pooled analysis was done to ascertain the perioperative and postoperative outcomes after surgery for CLDH. Additional comparative analysis was done compared to CLDH with non-calcified lumbar disc herniation (NCLDH) cases. RESULTS: We included 9 studies published between 2016 and 2022 in our review, 8 of these were retrospective. A total of 356 cases of CLDH were evaluated in these studies with a male preponderance (56.4%). Mean operative time was significantly lower in NCLDH cases compared to CLDH cases. The mean estimated blood loss showed a negative correlation with the percentage of males. Satisfactory clinical outcomes were observed in majority of patients. The risk of bias of the included studies was moderate to high. CONCLUSION: Surgical difficulties in CLDH cases leads to increase in operative time compared to NCLDH. Good clinical outcomes can be obtained with careful planning; the focus of surgery should be on decompression of the neural structures rather than disc removal.

Virtual reality is effective in the management of chronic low back ache in adults: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Chronic low back ache (CLBA) is a common condition that is conventionally managed with physical therapy and analgesics. Recently, virtual reality-based interventions have been tried out in the management of CLBA. Their effectiveness, however has not been established. This meta-analysis aims to find out if the application of VR will lead to better pain relief, as compared to conventional techniques in adults with CLBA. METHODS: The literature search was carried out in three online databases for potential randomized controlled trials that compared VR-based interventions with conventional treatment in CLBA. Data on outcome parameters were recorded. Meta-analysis was carried out with the help of appropriate software. RESULTS: Seven studies having data on 507 subjects were included in the meta-analysis. Their mean ages were 48.4 years. There were 252 subjects in the VR group and 255 in the control group. VR-based interventions were found to have a statistically significant improvement in the pain intensity compared with conventional techniques (p - 0.005). CONCLUSION: VR-based interventions are effective in the management of CLBA in the short term. Further research with longer follow-up is required to evaluate if these improvements are persistent in the long term.

Effect of obesity on results of endoscopic versus open lumbar discectomy: a systematic review and meta-analysis.

INTRODUCTION: Lumbar disc herniation in obese individuals poses unique surgical challenges which can influence outcomes in such patients. Limited studies are available evaluating the results of discectomy in obese persons. The aim of this review was to compare outcomes in obese and non-obese individuals; and to analyse whether approach to surgery had a bearing on these outcomes. METHODS: The literature search was conducted on four databases (PubMed, Medline, EMBASE, and CINAHL) and PRISMA guidelines were followed. After screening by the authors, eight studies were shortlisted from which data were extracted and analysed. Comparative analysis was done for lumbar discectomy (microdiscectomy or minimally invasive vs. endoscopic technique) between obese and non-obese groups from the six comparative studies in our review. Pooled estimates and subgroup analysis was done to ascertain the effect of surgical approach on outcomes. RESULTS: Eight studies published between 2007 and 2021 were included. Mean age of study cohort was 39.05 years. Mean operative time was significantly shorter in the non-obese group mean difference of 15.1 min (95% CI - 0.24 to 30.5). On subgroup analysis, obese individuals operated via endoscopic approach had significantly decreased operative time as compared to open approach. Blood loss and complication rates were also lower in the non-obese groups, but not statistically significant. CONCLUSION: Significantly less mean operative time was seen in non-obese individuals and when obese patients were operated via endoscopic approach. This difference between obese and non-obese groups was significantly more in the open subgroup as compared to the endoscopic subgroup. No significant differences in blood loss, mean improvement in VAS score, recurrence rate, complication rate and length of hospital stay was found between obese and non-obese patients as well as between endoscopic versus open lumbar discectomy within the obese subgroup. The learning curve associated with endoscopy makes it a challenging procedure.

Tuberculosis of the spine and drug resistance: a review article.

Pott's spine is tuberculosis of spine caused due to hematogenous spread of mycobacterium from a primary focus. It constitutes about 50% of skeletal tuberculosis cases. Paradiscal type is the most common type of spinal tuberculosis. Untreated cases can lead to complications like a cold abscess, paraplegia, and deformity which may require surgical intervention. Rapid molecular methods have made the diagnosis of spinal tuberculosis and drug resistance faster and easier but it still remains a problem due to difficulties in sample collection and the paucibacillary nature of the Pott spine. Antitubercular drug therapy forms the mainstay of management. The emergence of MDR TB and XDR TB has posed a big challenge in the management of spinal tuberculosis. The literature regarding drug resistance in spinal tuberculosis and its management is lacking. We conducted a literature review of 29 studies and presented information on pathogenesis, diagnosis, and management of spinal tuberculosis and drug resistance. New shorter regimens for MDR and XDR TB are under trial in different parts of the world. We believe this article will provide information on spinal tuberculosis and drug resistance and help clinicians outline important research areas.

Outcomes of cauda equina syndrome due to lumbar disc herniation after surgical management and the factors affecting it: a systematic review and meta-analysis of 22 studies with 852 cases.

PURPOSE: This study aimed to investigate the long-term clinical outcomes after surgical decompression in cauda equina syndrome (CES) and see if any preoperative patient-related factors contributed to this outcome. METHODS: A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Data regarding outcome parameters from eligible studies were extracted. Meta-analysis was performed using a random-effect model. RESULTS: A total of 852 patients (492 males and 360 females), with a mean age of 44.6 ± 5.5 years from 22 studies diagnosed with cauda equina syndrome and undergoing surgical decompression, were included in the meta-analysis; however, not all studies reported every outcome. The mean follow-up period was 39.2 months, with a minimum follow-up of 12 months in all included studies. Meta-analysis showed that on long-term follow-up, 43.3% [29.1, 57.5] (n=708) of patients had persistent bladder dysfunction. Persistent bowel dysfunction was observed in 31.1% [14.7, 47.6] (n=439) cases, sensory deficit in 53.3% [37.1, 69.6] (n=519), motor weakness in 38.4% [22.4, 54.4] (n=490), and sexual dysfunction in 40.1% [28.0, 52.1] (n=411). Decompression within 48 hours of the onset of symptoms was associated with a favourable outcome in terms of bladder function with 24.6% [1.6, 50.9] (n=75) patients having persistent dysfunction, whereas 50.3% [10.3, 90.4] (n=185) of patients in studies with a mean time to decompression after 48 hours had persistent bladder dysfunction. Other factors such as speed of onset and sex of the patients were not found to significantly impact long-term bladder outcomes. CONCLUSION: The long-term outcomes of CES after decompression are enumerated. Decompression within 48 hours of the onset of symptoms appears to result in fewer patients with persistent bladder dysfunction. However, a randomized controlled trial is required to conclusively determine whether early decompression leads to better outcomes.

Prognosticating acute traumatic spinal cord injury using Neurofilament (NF), Neuron Specific Enolase (NSE), Matrix Metalloproteinases (MMPs), and S-100B as biomarkers.

BACKGROUND: Spinal cord injury (SCI) can result in lifelong disability. Currently, the literature suggests that biomarkers are helpful in prognosticating SCI, but there is no specific biomarker to date. This is the first study that predicted the prognosis dynamically using biomarkers. AIM: To elucidate the role of biomarkers in prognosticating acute traumatic SCI. METHODS: Blood samples were obtained from 35 patients of acute traumatic SCI at presentation, immediate post-op, and at 6 weeks. At 6 months follow-up, patients were divided into two groups, i.e, improved and non-improved based on the improvement in the ASIA grade compared to presentation. A non-parametric test was used for comparing mean NSE, MMP-2, S100-B, and NF serum levels at presentation, immediate post-op, and 6 weeks post-op follow-up between the two groups. RESULTS: There was a significant difference (p = 0.03) in the NF values at presentation between the two groups. The difference of NSE values at 6 weeks was also significant (p = 0.016) between the two groups. S-100B levels were also significantly different between both groups at presentation (p=0.016), and at the immediate post-op stage (p=0.007). MMP-2 levels neither displayed any specific trend nor any significant difference between the two groups. CONCLUSION: Higher NF values at presentation, and higher S-100B levels at presentation and immediate post-operative period correlated with poor outcome. Also, increased NSE values after surgery are indicative of no improvement. These levels can be used at various stages to predict the prognosis. However, further studies are required on this topic extensively to know the exact cut-off values of these markers to predict the prognosis accurately. CLINICAL TRIALS REGISTRY NUMBER: REF/2020/01/030616.

The kickstand rod technique for correction of coronal malalignment in patients with adult spinal deformity: a systematic review and pooled analysis of 97 cases.

Coronal malalignment (CM) has recently gained focus as a key predictor of functional outcomes in patients with adult spinal deformity (ASD). The kickstand rod technique has been described as a novel technique for CM correction using an accessory rod on the convex side of the deformity. This review aimed to evaluate the surgical technique and outcomes of corrective surgery using this technique. The literature search was conducted on three databases (PubMed, EMBASE, and Scopus). After reviewing the search results, six studies were shortlisted for data extraction and pooled analysis. Weighted means for surgical duration, length of stay, amount of coronal correction, and sagittal parameters were calculated. The studies included in the review were published between 2018 and 2023, with a total sample size of 97 patients. The mean age of the study cohort was 61.1 years, with female preponderance. The mean operative time was 333.6 minutes. The mean correction of CM was 5.1 cm (95% confidence interval [CI], 3.6-6.6), the mean sagittal correction was 5.6 cm (95% CI, 4.1-7.1), and the mean change in lumbar lordosis was 17° (95% CI, 10.4-24.1). Preoperative coronal imbalance and mean correction achieved postoperatively were directly related with age. The reoperation rate was 13.2%. The kickstand rod technique compares favorably with conventional techniques such as asymmetric osteotomies in CM management. This technique provides an additional accessory rod that helps increase construct stiffness. Because of limited data, definitive conclusions cannot be drawn from this review; however, this technique is a valuable tool for a surgeon dealing with ASD.

Nuances in Growing Rod Surgery: Our Initial Experience and Literature Review.

Introduction: Growing rod construct is one of the most widely acknowledged treatment modalities for early-onset scoliosis around the world, but it is not without complications. Throughout the course of treatment, numerous planned and inadvertent surgical interventions are required, which increase the complexity of the treatment. We share our experience with case examples along with extensive literature search and review to get an insight and document the complications with growing rod treatment. Case Report: These cases underwent surgery with dual growing rod for thoracolumbar idiopathic scoliosis in the view of failed conservative treatment and progressive deformity. Superficial infection is in one case and recurrence of deformity was a common finding though correction of deformity and final fusion was achieved in the cases. Breakage of screws, autofusion of the spanned segments, and profuse bony growths over the implants are common finding to get. Fibrosis and scar tissue from the previous surgeries result in difficulty in the exposure and performing corrective osteotomy. Conclusion: Growing rod surgery has high complication rates. Repeated surgical and anesthesia exposure pose a great risk to the body and immature skeleton of the young patient. Previous studies have put forth many possible course of action to lower down the complication rates but have met with variable results. A better implant design and surgical efficacy are needed to cut down the number of complications and surgical interventions in growing rod surgeries.

Subjacent Disease in an Operated Case of Spinal Tuberculosis: A Case Report and Literature Review.

Introduction: Spinal tuberculosis (TB) recurrence in subjacent vertebral segments in a post-operative case is one of the atypical presentations of this common disease. Case Report: A 63-year-old gentleman presented with fever and bilateral lower limb weakness for 10 days. The patient was on anti-tubercular therapy for the past 18 months and had a history of surgical decompression and posterior instrumentation for D12 and L1 vertebrae spinal TB. Radiological investigations showed new-onset TB in D9 and D10 vertebral levels. Management with revision surgery was done. Conclusion: Recurrence of spinal TB in segments of vertebrae subjacent to previously operated segments in a patient on long-term anti-tubercular treatment is a rare and undescribed presentation of the common disease. High index of suspicion is required for early diagnosis and prompt management to prevent long-term morbidities.

Ultrasonic Bone Scalpel versus Conventional Methods for Osteotomy in Posterior Surgery for Cervical Spondylotic Myelopathy: A Review and Meta-Analysis.

Posterior methods for cervical myelopathy include laminoplasty and laminectomy with/without fusion. A more recent innovation in these treatments is the use of an ultrasonic bone shaver for osteotomy. In this study, we examined the perioperative results after laminectomy/laminoplasty between conventional methods (rongeur/high-speed drill) vs. piezosurgery-based instruments. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed and the search was performed on four databases (PubMed, Scopus, EMBASE, and Google Scholar). Seven comparative studies were chosen after thorough screening by the authors and a meta-analysis was performed between piezosurgery and conventional technique to ascertain intraoperative and postoperative results after laminectomy/laminoplasty. The analysis includes four retrospective cohort studies and three randomized controlled trials published between 2015 and 2022. The mean age ranged from 55.5 to 64.2 years. Blood loss was significantly reduced in the piezosurgery group, other findings were not significant. On subgroup analysis, laminoplasty dramatically reduced blood loss and the rate of iatrogenic dural rips in the piezosurgery group. The use of ultrasonic bone shaver for osteotomy in cervical spondylotic myelopathy is related to significantly decreased blood loss and no significant increase in postoperative drainage, operative time, complication rate, and functional outcomes as compared to traditional techniques. We noticed significantly reduced blood and rate of dural tears in the laminoplasty subgroup with the use of ultrasonic bone shaver, which was not mirrored in the laminectomy subgroup. Careful intraoperative handling of the instrument can help prevent iatrogenic dural tears and nerve damage.

Isolated Retropulsion of C5 Cervical Vertebral Body without any Displacement of Facet Joints: A Case Report on an Unusual Presentation of Cervical Spine Injury.

Introduction: The sub axial cervical spine is a common site for traumatic spine injury, the injury of which can be life-threatening and can also result in permanent disability. Subaxial cervical spine injury has been classified by Allen and Ferguson (earliest classification), subaxial cervical spine injury classification system (SLICS) and AO spine classification. Allen and Ferguson system has significant inter-observer variations and is difficult to apply clinically at times. SLICS does not guide in the choice of surgical approach and score can vary between individuals because of different magnetic resonance imaging interpretations for discoligamentous injury. AO spine classification system has low agreement rate for intermediate morphology types (A1-4 and B) and not all injury patterns fit in the AO spine classification system like the case presented herein. In this case report, we address an unusual presentation of the flexion-compression mechanism of injury. This fracture morphology does not fit in any of the above mentioned classification system, so we are reporting this case and this is the first report of this kind in the literature. Case Report: An 18-year-old male presented to our emergency department with a history of fall of heavy object on his head from above. On presentation, the patient was in shock and respiratory distress. The patient was intubated and resuscitated gradually. Non-contrast computed tomography of the cervical spine showed isolated retropulsion of the C5 body without any displacement of facet joints or pedicle fracture. This injury was also associated with a fracture of the posterosuperior portion of the C6 vertebral body. The outcome was the death of the patient 2 days after injury. Conclusion: The cervical spine is a common segment of the spine that is prone to injuries due to its anatomy and flexibility. The same injury mechanism can lead to varied and unique presentations. Each classification system for cervical spine injury has its drawback, cannot be universalized, and more research is needed to develop a classification system with an international agreement for diagnosing, classifying, and treating the injury for better patient outcomes.

Minimally Invasive Surgery versus Open Surgery for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis.

Minimally invasive surgery (MIS) is being recommended over more invasive methods. MIS advantages are less time in the operating room, less blood loss, a shorter recovery time, and shorter length of stay. A systematic review and meta-analysis were performed using the literature from minimally invasive and open surgery for adolescent idiopathic scoliosis (AIS). We conducted this analysis to see whether MIS has advantages over traditional surgery. A systematic review was conducted using PubMed, Embase, and Scopus to find articles comparing minimally invasive and open surgery techniques for AIS patients. Data extraction and meta-analysis were completed. The primary data points collected were correction rate and functional outcomes, including perioperative and postoperative parameters. A total of six studies were included in the final analysis. The MIS group had 123 patients, and the open surgery group had 150 patients. The correction rate and functional outcomes favored the open surgery group with a mean difference of 4.60 (95% confidence interval [CI], 0.08 to 9.12) and 0.11 (95% CI, 0.04 to 0.17), respectively. The duration of surgery, blood loss, number of patients requiring transfusion, and analgesic requirements favored the MIS group with a significant difference. Open surgery is better than MIS in achieving a better correction rate and good functional outcomes. MIS is better over open surgery when perioperative parameters are considered.

Application of Modest Hypothermia in Patients with Acute Traumatic Cervical Spine Injury: A Pilot Study.

Introduction: This prospective randomized controlled study aimed to examine the role of modest systemic hypothermia in individuals with acute cervical spinal cord injury (SCI) regarding neurological improvement. Studies have shown that the application of hypothermia is safe and that it improves neurological outcomes in patients with traumatic spine injury. Hypothermia helps in decreasing a secondary damage to the cord. Methods: Twenty cases of acute post-traumatic cervical SCI with AISA were selected and randomly divided into two treatment groups: Group A-Hypothermia with surgical decompression and stabilization; and Group B-Normothermia with surgical decompression and stabilization. American Spinal Injury Association (ASIA) motor and sensory scores were evaluated at presentation; post-surgery; and at a 2-week, 6-week, and 12-week follow-up. Results: At the final follow-up, the change in ASIA motor scores of Group A was 46 (11.5-70.5) and Group B 13 (4.5-58.0), whereas ASIA sensory scores were 118 (24.75-186.5) and 29 (15.25-124.0) in Group A and Group B, respectively. ASIA scores between the two groups were statistically significantly different at a 2-week follow-up (ASIA motor p=0.04, ASIA sensory p=0.006), showing early improvement in the hypothermia group. There was no significant difference between the two groups on further follow-up. Conclusions: Hypothermia can be applied safely to subjects with acute SCI. Our study showed that hypothermia was beneficial in the early improvement of functional outcomes in acute cervical SCI.

Simultaneous bilateral anterior shoulder dislocation: report of two cases and review of the literature.

Bilateral shoulder dislocations are rare and almost always occur in the posterior direction. Simultaneous bilateral anterior shoulder dislocation is even rarer and only a few cases are stated in the literature. The most interesting part of a bilateral shoulder dislocation is about its injury mechanism as a synchronous and simultaneous force is needed to result in it. In cases of epilepsy or electrocution, the mechanism is different and the forceful contractions of the selective group of muscles result in the dislocation. This article reports two cases of bilateral simultaneous anterior shoulder joint dislocation that occurred after a road side accident and after an episode of convulsion in an epileptic patient. The dislocations were diagnosed early and reduced immediately with a proper postreduction rehabilitation. During their follow-up, both patients had sa-tisfactory functional outcome. This article emphasizes on the importance of shoulder examination in road side accident victims and epileptic patients. All orthopedic surgeons and emergency physicians should be aware of such unusual possibilities to have an early diagnosis and treatment. An early reduction and appropriate rehabilitation can provide satisfactory functional outcome. This article also briefly discusses the injury mechanisms, diagnoses and treatments of bilateral shoulder dislocation as reported in the literature.

Mycobacterium tuberculosis Infection of the Spine Secondary to Oxygen - Ozone Therapy for Prolapse Intervertebral Disc: A Scoping Review.

Introduction: Ozone therapy is one of the evolving, yet far from conclusive, alternative minimally invasive treatment option in the management of herniated disc in the cervical and lumbar spine. It causes the decrease in the volume of herniated disc by dehydration. Case Report: We hereby present the first reported case of Mycobacterium infection of the spine secondary to ozone therapy with the aim to caution the surgeons regarding the complications of intradiscal ozone therapy. Conclusion: Lack of proper, adequate, and recommended precautions if not taken can inoculate the varied microorganisms into the intradiscal space leading to devastating and unforeseen complications.

Need for Testing and Supplementation of Vitamin D3 After Release of COVID-19 Lockdown in Patients with Increased Musculoskeletal Pain.

AIMS: To evaluate vitamin D3 levels in patients who presented with increased musculo-skeletal pain after release of lockdown period when compared to pre-lockdown status. INTRODUCTION: During this COVID pandemic, many countries have implemented lockdown measures and people have to work from home and many students and workers have to restrict themselves to home. During this period, their outdoor activities were limited. After the partial release of this lockdown many of them started to have some kind of physical activity and started experiencing body pains. We evaluated such patients for vitamin D3 levels and symptoms of fibromyalgia. METHODS: This is a retrospective analysis of patients from age group 18-60 presented to outpatient department or on telephonic consultation after partial release of lockdown. All patients who had mild back ache before lockdown and had symptoms exaggerated during this lockdown release were included. All patients were investigated for vitamin D3, PTH, thyroid profile, liver functional and kidney functional tests. RESULTS: Out of 120 patients presented to us in a period of 3 months, 31 patients had increased symptoms when compared to pre-lockdown status. 20 out of 31 patients had low vitamin D3 levels. 14 patients also developed symptoms of fibromyalgia. CONCLUSION: There might be many reasons for increased pain during lockdown, but we focussed specially only on vitamin D3 because of its association with increased symptoms of COVID-19. This is a gentle reminder to test for vitamin D3 levels and supplement if found deficient. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00376-8.

Contrast Medium Volume Needed to Reach Anterior Epidural Space via the Kambin Triangle or Subpedicular Approach for Transforaminal Epidural Injection.

BACKGROUND: Transforaminal (TF) lumbar injection is a commonly used minimally invasive intervention for management of chronic low back pain. TF injection can be performed using various approaches to inject the drug to the anterior epidural space (AES). OBJECTIVES: To identify the volumes of contrast medium needed to reach the AES and other landmarks in the Kambin triangle (KB) and subpedicular (SP) approach of TF injection in patients with lumbosacral radicular pain. STUDY DESIGN: Randomized controlled trial. SETTING: Pain clinic and operating room of a tertiary care hospital. METHODS: Seventy-five eligible patients were randomized to receive TF epidural injection either by SP (SP group; n = 38) or the KB (KB group; n = 37) approach under fluoroscopic guidance. After confirming the appropriate needle position, contrast medium was injected at 0.5 mL increments up to 2 mL under intermittent fluoroscopy. Contrast medium volumes needed to reach specific landmarks, that is, AES, medial to superior pedicle, medial to inferior pedicle, medial aspect of both the superior, and neural spread, were recorded. Following this, 4 mL of the drug (0.5% lidocaine 1 mL + methylprednisolone 80 mg + 1 mL normal saline solution) was injected. Patients were evaluated for Visual Analog Scale (VAS) and modified Oswestry Disability Questionnaire (MODQ) scores after epidural injections at 2 weeks, 1 month, and 2 months. RESULTS: Average volume of contrast medium needed to reach AES was 1.10 ± 0.46 mL in the KB approach and 1.10 ± 0.38 mL in the SP approach. Contrast medium volume needed to reach other landmarks showed comparable results in both groups. AES was seen in 27.02% (10/37) patients in the KB group and 23.6% (9/38) patients in the SP group with 0.5 mL of contrast medium. This increased to 56.76% (21/37) and 77.7% (28/38) with 1 mL of contrast medium (P = 0.03, chi-square test). No anterior spread was seen even after 2 mL of contrast medium in 4 patients in the KB group and 2 patients in the SP group. Neural spread was seen in 100% of patients in the KB group after 0.5 mL of contrast medium, but in 34 (89.4%) patients in the SP group (P = 0.03, chi-square test). We did not note any contralateral spread. Short-term effectiveness in pain relief in terms of VAS for back pain and functional improvement in terms of MODQ score over time showed similar results in both groups. Intravascular needle puncture and needle paresthesia was comparable in both groups. LIMITATIONS: Small follow-up duration is one the limitations of this study. Future studies will be needed to assess any long-term differences in outcome between approach methods. Also, use of intermittent fluoroscopy might have limited detection of intravascular injections of the contrast medium in comparison to the continuous fluoroscopy. CONCLUSIONS: To conclude, our study revealed that average volume of contrast medium needed to reach AES and other landmarks were comparable with both approaches of TF injection. KEY WORDS: Transforaminal injection, subpedicular approach, Kambin triangle approach, contrast medium spread, anterior epidural spread.