The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data.

OBJECTIVE: To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain. DESIGN: Comprehensive systematic review. OUTCOME MEASURES: The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery. RESULTS: For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58-68%) at one month, 74% (68-80%) at three months, 64% (59-69%) at six months, and 64% (57-71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43-55%) at one month, 48% (35-61%) at three months, 43% (33-53%) at six months, and 59% (45-73%) at one year, but there was a lack of corroboration from appropriately controlled studies. CONCLUSIONS: There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.

Risks and Benefits of Ceasing or Continuing Anticoagulant Medication for Image-Guided Procedures for Spine Pain: A Systematic Review.

Objective: To determine the risks of continuing or ceasing anticoagulant or antiplatelet medications prior to image-guided procedures for spine pain. Design: Systematic review of the literature with comprehensive analysis of the published data. Interventions: Following a search of the literature for studies pertaining to spine pain interventions in patients on anticoagulant medication, seven reviewers appraised the studies identified and assessed the quality of evidence presented. Outcome Measures: Evidence was sought regarding risks associated with either continuing or ceasing anticoagulant and antiplatelet medication in patients having image-guided interventional spine procedures. The evidence was evaluated in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system. Results: From a source of 120 potentially relevant articles, 14 provided applicable evidence. Procedures involving interlaminar access carry a nonzero risk of hemorrhagic complications, regardless of whether anticoagulants are ceased or continued. For other procedures, hemorrhagic complications have not been reported, and case series indicate that they are safe when performed in patients who continue anticoagulants. Three articles reported the adverse effects of ceasing anticoagulants, with serious consequences, including death. Conclusions: Other than for interlaminar procedures, the evidence does not support the view that anticoagulant and antiplatelet medication must be ceased before image-guided spine pain procedures. Meanwhile, the evidence shows that ceasing anticoagulants carries a risk of serious consequences, including death. Guidelines on the use of anticoagulants should reflect these opposing bodies of evidence.

The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data.

OBJECTIVE: To determine the effectiveness and risks of non-image-guided lumbar interlaminar epidural steroid injections. DESIGN: Systematic review. INTERVENTIONS: Three reviewers with formal training and certification in evidence-based medicine searched the literature on non-image-guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. OUTCOME MEASURES: The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids, and complications were noted, if reported. The evidence was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. RESULTS: The searches yielded 92 primary publications addressing non-image-guided lumbar interlaminar epidural steroid injections. The evidence supporting the effectiveness of these injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis is limited. This procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. In accordance with GRADE, the quality of evidence is very low. CONCLUSIONS: In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Sacroiliac Joint Injection? A Multicenter Cohort Study.

OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during intra-articular sacroiliac joint (SIJ) injections performed for a pain indication. DESIGN: Multicenter retrospective cohort study. SETTING: Three academic, outpatient pain treatment centers. SUBJECTS: Patients who underwent fluoroscopy guided SIJ injection with encounter data regarding fluoroscopy time during the procedure and body mass index (BMI). MAIN OUTCOME MEASURE: Median and 25-75% Interquartile Range (IQR) fluoroscopy time. RESULTS: 459 SIJ injections (350 patients) were included in this study. Patients had a median age of 57 (IQR 44, 70) years, and 72% were female. The median BMI in the normal weight, overweight, and obese groups were 23 (IQR 21, 24), 27 (IQR 26, 29), and 35 (IQR 32, 40), respectively. There was no significant difference in the median fluoroscopy time recorded between these BMI classes (p = 0.45). First-time SIJ injection (p = 0.53), bilateral injection (p = 0.30), trainee involvement (p = 0.47), and new trainee involvement (trainee participation during the first 2 months of the academic year) (p = 0.85) were not associated with increased fluoroscopy time for any of the three BMI categories. CONCLUSIONS: Fluoroscopy time during sacroiliac joint injection is not increased in patients who are overweight or obese, regardless of whether a first-time sacroiliac joint injection was performed, bilateral injections were performed, a trainee was involved, or a new trainee was involved.

Interlaminar versus transforaminal epidural steroid injections for the treatment of symptomatic lumbar spinal stenosis.

BACKGROUND: Lumbar spinal stenosis is a common condition that causes axial low back pain, radicular pain, and neurogenic claudication. Epidural steroid injections are commonly used for the treatment of radicular symptoms and neurogenic claudication associated with symptomatic lumbar spinal stenosis. No prior study has evaluated whether transforaminal or interlaminar epidural steroid injections produce better clinical outcomes. DESIGN: Retrospective case control study. METHODS: For each technique, 19 patients were retrospectively identified who received their first fluoroscopically guided epidural steroid injection for radicular and neurogenic claudication symptoms caused by lumbar spinal stenosis over a 12-month interval. All patients had corresponding MRI findings and had failed previous non-invasive therapies. Outcomes included the visual analog scale (VAS, 0-10 scale) immediately before the injection, immediately after the injection, and upon follow up at 4-6 weeks. Surgery rates and number of repeat injections over a 3 year period were also analyzed. The patient groups were matched for age and level of stenosis on MRI. RESULTS: There was no statistically significant difference between the two groups in pre injection to follow up VAS scores (P=0.919). The difference between number of repeat injections between the interlaminar and transforaminal groups was not statistically significant (0.91-mean 2.47 and 2.58, respectively). Both the interlaminar and transforaminal groups experienced statistically significant improvement in VAS scores from before the injection to after the injection, and on follow up. Low numbers underwent surgery (11% in the interlaminar group vs 15% in the transforaminal group, not significant, P=0.63). CONCLUSIONS: In the current study, neither transforaminal nor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions or repeat injections when compared with each other.

A report of paraparesis following spinal cord stimulator trial, implantation and revision.

BACKGROUND: Spinal cord injury has been reported as a rare complication of spinal cord stimulation (SCS). A review of the literature shows a very low incidence of neurological injury after spinal cord stimulation trial, implantation and revision. The most common reported complication is equipment failure without neurologic injury. The incidence of spinal cord injury after SCS trial, implantation and revision is unknown. There have been limited reports of neurologic injury secondary to dural puncture, infection, cord contusion, actual needle penetration of the spinal cord and epidural hematoma. STUDY DESIGN: A report of 4 cases. OBJECTIVE: To report 4 occurrences of neurological complication after spinal cord stimulator implantation. METHODS: Four patients are presented who were admitted to an acute spinal cord rehabilitation hospital over a 4-month period. All 4 patients presented with paraparesis after spinal cord stimulator trial or implantation. One of the injuries is secondary to cord contusion, while the other 3 are secondary to cord compressions. Two of these compressions are due to epidural hematomas and one secondary to implantation in the setting of broad based thoracic disc herniations. The clinical cases are presented as well as a review of the literature. RESULTS: All 4 patients had the electrodes and neurostimulators successfully removed prior to their acute rehabilitation admissions. At discharge from acute inpatient rehabilitation, one patient continued to experience complete paraplegia, 2 patients had incomplete paraparesis and one had fully recovered all of his neurologic function. CONCLUSION: SCS is considered a safe procedure. Further investigation into the true incidence of neurologic injury after SCS is warranted.