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

BACKGROUND: Transforaminal epidural injections (TEI) can alleviate symptoms and help to maintain physical functioning and quality of life in patients with lumbar radicular pain. We aim to develop a prediction model for patient outcome after TEI in patients suffering from unilateral lumbar radicular pain due to lumbar disc herniation (LDH) or single-level spinal stenosis (LSS). The secondary aim is to estimate short-term patient outcome differences between LDH and LSS patients, the association between psychological variables and patient outcome, the rate of additional injections, surgery and complications, and to explore the short-term cost-effectiveness of TEI. METHODS: This study is designed as a multi-centre, observational, prospective cohort study in two large regional hospitals in the Netherlands. Patients diagnosed with unilateral lumbar radicular pain secondary to LDH or LSS and congruent with MRI findings, who are referred for TEI along usual care pathways, are eligible for study participation. A total of 388 patients with LDH or LSS will be included. A pre-defined set of demographic, clinical and radiological variables will be used as the predictors in the model. The primary outcome measure is the Numerical Rating Scale (NRS) for leg pain. Secondary outcome measures include back pain, physical functioning, perceived recovery, pain coping strategies, anxiety and depression and use of analgesics and physical therapy. Patients will be evaluated at baseline, 2 weeks and 6 weeks after treatment. NRS leg pain and Likert perceived recovery data will be used as the dependent variables in a generalized linear mixed model for prediction of TEI outcome, with internal validation of performance (explained variation) by bootstrap resampling. Cost-effectiveness for a period of 6 weeks prior to and after treatment will be performed with decision-analytic modelling. DISCUSSION: Patients with severe lumbar radicular pain often request additional treatment when conservative care is insufficient. TEI can offer relief of symptoms. Currently, it is not possible to predict responsiveness to this treatment for individual patients. This study is designed to explore predictors that can differentiate between patients that will and will not have a positive outcome after TEI. This information may support treatment strategies for this patient group. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov database under registry number NCT04540068 on September 1, 2020.

Caudal epidural steroid injection versus transforaminal ESI for unilateral S1 radiculopathy: a prospective, randomized trial.

OBJECTIVE: Epidural steroid injections are frequently performed to manage radicular symptoms. Most research investigating the effectiveness of different routes of epidural injections were conducted with non-homogeneous groups. In this study our aim was to investigate the efficacy of caudal versus transforaminal approaches in patients with unilateral S1 radiculopathy secondary to a paracentral L5-S1 disc herniation. STUDY DESIGN: Prospective, randomized clinical trial. SETTING: A university hospital pain management center. METHODS: The study was conducted between January 2022 and February 2023. Patients with unilateral S1 radiculopathy were randomly divided into two groups: the caudal epidural steroid injection (CESI) and the transforaminal epidural steroid injection (TFESI) group. Severity of pain and disability were assessed with Numeric Rating Scale (NRS-11) and Oswestry Disability Index (ODI) at baseline, 3 weeks, and 3 months after treatment. Fifty percent or more improvement in NRS-11 was defined as treatment success. Fluoroscopy time and doses of exposed radiation were also recorded. RESULTS: A total of 60 patients were included in the final analysis (n = 30 for each group). Significant improvement in pain and disability scores was observed at 3rd week and 3rd month compared to baseline (P < .001). Treatment success rate at 3rd month was 77% for the CESI group and 73% for the TFESI group without any significant difference between the groups (P = .766). CONCLUSIONS: CESI is equally effective as TFESI in the management of S1 radiculopathy due to a paracentral L5-S1 disc herniation. Both approaches can reduce pain and disability, while CESI requires shorter fluoroscopy time and less radiation exposure.

Rationale for fluoroscopic guidance in spine injections.

Spine injections are commonly performed in the treatment of back pain. The purpose of this article is to review the current literature surrounding image guided spine injections focusing on scenarios where fluoroscopic guidance can be advantageous in addition to discussing similarities among the different modalities.

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

OBJECTIVE: The aim of this study was to invastigate the effect of the sacralization on the results of transforaminal epidural steroid injection for radicular low back pain. MATERIALS AND METHODS: The study included 64 patients diagnosed with radicular low back pain due to unilateral and single-level lumbar disk herniation. Patients were divided into 2 groups: patients with sacralization (Group S) and patients without lumbosacral transitional vertebrae (Group A). Injection was applied to the relevant level. Patients were evaluated with Numeric Rating Scale and Modified Oswestry Disability Index before, at week 3 and month 3 after the procedure. Sacralization presence was determined by MRI. Sacralization was categorized by anteroposterior lumbar radiography using Castellvi classification. Treatment success was considered as ≥ 50% reduction in NRS scores. RESULTS: Numeric Rating Scale and Modified Oswestry Disability Index scores decreased in both groups on both week 3 and month 3 (p < 0.05). Pain scores of Group S (median value 5 (3-6)) were significantly higher than Group A ((median value 3 (0-5)) in the third month follow-up (p = 0.026), but no significant difference was observed at other time points. There was no significant difference in Modified Oswestry Disability Index scores between the groups at all follow-ups (p > 0.05). Treatment success in the third month was 44.8% in Group S and 65.6% in Group A. CONCLUSION: Transforaminal epidural steroid injection is an effective and safe method for radicular low back pain. Sacralization presence should be evaluated before treatment considering that it may be a risk factor reducing treatment success.

Safety of local anesthetics in cervical nerve root injections: a narrative review.

Severe neurological adverse events have been reported after fluoroscopically guided cervical nerve root injections. Particulate corticosteroids inadvertently injected intraarterially and iatrogenic vertebral artery trauma have been implicated in these outcomes. This has raised concern for the potential consequences of including local anesthetic with these injections. As a result, some providers have now discontinued the routine administration of local anesthetic with corticosteroid when performing cervical nerve root injections. At present, there is no consensus regarding whether the use of local anesthetic in this context is safe. Here, the current literature is synthesized into a narrative review aiming to clarify current perspectives of the safety of local anesthetics in cervical nerve root injections.

Injection into the Space of Okada During Transforaminal Epidural Steroid Injections.

OBJECTIVE: Ensuring medication delivery to the epidural space is crucial for effective transforaminal epidural steroid injections. Epidural needle placement is determined by injecting a small amount of contrast at the final needle position. The purpose of this study is to illustrate the appearance of contrast flow in the retrodural retroligamentous space of Okada during computed tomography- and fluoroscopy-guided cervical and lumbar transforaminal epidural steroid injections. DESIGN: This retrospective study will use a series of cases to demonstrate contrast within the space of Okada during epidural transforaminal steroid injections. SETTING: Tertiary medical center. SUBJECTS: Study subjects are adult patients who underwent transforaminal epidural steroid injection at our institution. METHODS: Cases were identified through the use of a search engine of existing radiology reports at our institution. Epidural steroid injection procedural reports were searched for the terms "Okada" and "retrodural space." Images from the procedure were reviewed by the authors (all proceduralists with dedicated training in spinal injections) to confirm the presence of contrast within the space of Okada. RESULTS: This case series illustrates six examples of contrast injection into the retrodural space of Okada during cervical and lumbar transforaminal epidural steroid injections. CONCLUSIONS: Contrast uptake in the retrodural space of Okada may be seen during transforaminal epidural injections. Although relatively uncommon, it is likely underrecognized. It is extremely important that providers who perform transforaminal epidural steroid injections be familiar with this non-epidural contrast flow pattern so they can adjust needle positioning to deliver steroid to the epidural space.

Factors associated with treatment success after combined transforaminal epidural steroid injection and dorsal root ganglion pulsed radiofrequency treatment in patients with chronic lumbar radicular pain.

BACKGROUND: The aim of the study is to identify predictors of treatment success with combined transforaminal epidural steroid injection (TFESI) and dorsal root ganglion pulsed radiofrequency (DRG-PRF) in patients with lumbar radicular pain (LRP) associated with lumbar disc herniation. METHODS: The study included 48 patients with herniation-related LRP who underwent TFESI and DRG-PRF treatment between November 1, 2020 and April 30, 2021. Patient age, sex, symptom duration, history of lumbar surgery, and numeric rating scale (NRS) pain scores before and at 10 days, 1 month, and 3 months after treatment were evaluated retrospectively. Treatment success was defined as ≥50% improvement or a 4-point decrease in NRS score at 3 months. RESULTS: Twenty-nine female and 19 male patients with a mean age of 51.54 ± 13.31 years were analyzed. The median symptom duration was 6 (interquartile range: 8.50) months. Symptom duration did not affect treatment success (p = 0.105). History of spinal surgery was more common among patients with failed treatment but was not statistically associated with treatment success. A 1-unit increase in pre-treatment NRS score was associated with 72% lower odds of treatment success (p = 0.022), while a 1-unit increase in NRS score on post-treatment day 10 compared to the pre-treatment value was associated with 95% lower odds of treatment success (p = 0.008). DISCUSSION: Symptom duration and history of spinal surgery were not predictive of treatment success with combined TFESI and DRGPRF for herniation-related LRP. However, the 3-month prognosis was significantly better for patients with a marked reduction in NRS score at 10 days.

Transforaminal epidural steroid injection combined with radio frequency for the treatment of lumbar disc herniation: a 2-year follow-up.

BACKGROUND: To assess the therapeutic efficacy of transforaminal epidural steroid injection (TFESI) combined with radio frequency (RF) for the treatment of lumbar disc herniation (LDH). METHODS: A total of 230 patients participated in the study: TFESI (Group T, n = 110), TFESI combined with RF (Group TR, n = 120). Visual analogue scale (VAS), Oswestry disability index (ODI) and Global perceived effect (GPE) scale were measured pre-operation, 1, 3, 6, 12 and 24 months after the operation. Hospitalization time, treatment time, complications, and recurrence were compared between the two groups. RESULTS: The VAS and ODI at each observation point of the post-operation were significantly decreased compared with the pre-operation in both groups (P < 0.05). There was no statistically difference of VAS and ODI between the two groups at 1 and 3 months of the post-operation (P > 0.05). However, The VAS and ODI scores in Group TR were significantly lower than that in Group T at 6, 12 and 24 months of the post-operation (P < 0.05). The GPE in group TR was high in the early days, while that at 1 and 3 months after treatment was significantly higher than that in group T (P < 0.05). The recurrence rate in Group TR was lower than that in Group T (P = 0.002). There was no significant difference in hospitalization time, complications, VAS and ODI score at the pre-operation between the two groups (P > 0.05). CONCLUSION: These findings suggest that TFESI combined with RF could effectively improve the pain and function, and had a long-term satisfactory effect for the treatment of LDH.

Qualitative Sensory Testing in Outcome Prediction of Transforaminal Epidural Steroid Injection for Chronic Painful Unilateral Lumbosacral Radiculopathy: Prospective Observational Study.

BACKGROUND: Transforaminal epidural steroid injection (TFESI) is widely practiced for the treatment of radicular pain. As its effectiveness is still subject to debate, a better patient selection for TFESI is necessary. We aimed to evaluate the potential of bedside-suitable qualitative sensory testing (QualST) to determine the early effectiveness of TFESI for the treatment of chronic lumbosacral radiculopathy (LSR)-related pain. METHODS: Thirty-six patients with chronic painful unilateral LSR were evaluated in a prospective observational study using five standardized sensory tests (10 g monofilament, 200 to 400 mN brush, Lindblom rollers with controlled 25 and 40°C temperature, and 40 g neurological pin). Quality of sensory perceptions on the painful leg was compared to the non-painful leg and rated as normal sensitivity, hyposensitivity, or hypersensitivity. Pain and related characteristics were evaluated before TFESI, 1 week after and 4 weeks after intervention. RESULTS: Seven sensory phenotypes were distinguished according to individual sets of sensory disturbances acquired with five sensory tests. Patients were grouped into four groups of allied phenotypes (normal sensitivity, hyposensitivity to 1 to 3 modalities, hyposensitivity to 4 to 5 modalities, and hypersensitivity). The whole study group showed significant improvement in most parameters of outcome measurements. Statistical analysis revealed some significant differences between sensory groups in patient-reported treatment effect scales after 4 weeks. We also detected significant differences between sensory groups in repeated measures after 1 and 4 weeks in some pain intensity characteristics and patient-reported treatment effect scales. CONCLUSION: QualST might be clinically applicable for detecting patient subgroups that could differ in the early treatment results of radicular pain by TFESI.

Long-term outcomes of transforaminal epidural steroid injection in patients with lumbosacral radicular pain according to the location, type, and size of herniated lumbar disc.

OBJECTIVES: Transforaminal epidural steroid injection (TFESI) is widely used to manage lumbosacral radicular pain due to herniated lumbar disc (HLD). OBJECTIVES: We evaluated the long-term outcomes of TFESI in patients with lumbosacral radicular pain due to an HLD by the location, type, and size of the HLD. METHODS: In total, 114 patients who received the initial TFESI at least 4 years ago completed a telephone interview. We investigated the presence of radicular pain, degree of current pain, current pain medications and TFESIs, additional TFESIs, progression to surgery, and trouble in performing daily life activities and occupational job duties. We classified the included patients by the location, type, and size of the HLD, and evaluated whether these factors affected the long-term outcomes of TFESI. RESULTS: At least 4 years after the initial TFESI, radicular pain was completely resolved in 45% of the patients. However, 30% patients were on oral painkillers or repetitive TFESIs or had undergone surgery and 15% had difficulty in performing daily life activities and occupational job duties. A larger number of patients with extruded lumbar disc herniation required additional TFESIs than those with protruded lumbar disc herniation. Apart from this, the outcomes did not significantly differ by the location, type, and size of the HLD. CONCLUSIONS: Our findings provide useful information to clinicians managing radicular pain due to HLD.

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations.

BACKGROUND AND PURPOSE: Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. METHODS: A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. RESULTS: The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa-tient's ODI scores was found statistically significant (p = 0.001). CONCLUSION: This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

The safety and efficiency of performing cervical transforaminal epidural steroid injections under fluoroscopic control on an ambulatory/outpatient basis.

PURPOSE: Cervical transforaminal epidural steroid injections (CTFESIs) have become an increasingly utilised means of treating radicular pain over recent decades, although a number of reports have brought their safety into question. Much of this has been attributed to the use of particulate steroids and the theoretical risk of embolic complications with inadvertent intra-arterial injection. This study documents the complications encountered at our centre when performing CTFESI over a more than 10-year study period with predominant use of particulate steroid. Our procedural technique is also described. This study aims to highlight the importance of operator technique first and foremost and how, with safe and reproducible technique that confidently avoids intra-arterial injection, CTFESI can be performed safely irrespective of the choice of steroid. METHODS: All patients undergoing CTFESI between January 2008 and August 2018 at our centre were prospectively recruited to the study, documenting total number of injections/procedures per patient, presence of/description of complications and severity and type of steroid administered. RESULTS: Five hundred and twenty-seven patients underwent 1047 procedures (1753 individual cervical levels injected) over the study period: 1011 procedures performed with particulate steroid (triamcinolone acetonide) and 36 performed with non-particulate (dexamethasone). Only six complications were encountered, all spontaneously self-resolving without intervention and considered minor (grade 1). CONCLUSIONS: With fastidious safe technique, CTFESI can be safe, efficacious and cost-effectively administered on an outpatient basis. Predominant use of particulate steroids did not lead to any significant complications. These slides can be retrieved under Electronic Supplementary Material.

At Least 5-Year Follow-up After Transforaminal Epidural Steroid Injection Due to Lumbar Radicular Pain Caused by Spinal Stenosis.

OBJECTIVES: Transforaminal epidural steroid injection (TFESI) can be used to control radicular pain following lumber spinal stenosis (LSS). However, limited information is available on the long-term prognosis of TFESI in patients with LSS. METHODS: Of the 90 patients who underwent TFESI for controlling LSS-induced radicular pain at least 5 years previously, 54 patients completed a phone interview. We inquired about their degree of pain during walking or standing, current oral medication used for radicular pain, current TFESI injections, progression to surgery, and unemployment due to pain at least 5 years after the TFESI for LSS-induced radicular pain. RESULTS: Five to seven years after the initial TFESI, the numeric rating scale (NRS) score had decreased from 6.7 to 3.7. Of the included patients, approximately 65% of the patients had an NRS score of ≥3, although roughly 15% of patients reported complete resolution of the initial pain. Approximately half of the included patients were currently receiving repetitive TFESIs every 2 to 6 months or were taking oral pain medications. Further, approximately 25% of the patients had undergone a surgical intervention; however, its outcome was poor. CONCLUSION: The prognosis after TFESI for controlling LSS-induced radicular pain is thought to be relatively poor. However, considering poor long-term outcome and complications after surgery, we believe that TFESI is worth considering as a safe modality for controlling radicular pain following LSS.

Comparison of 1-year results of single transforaminal epidural steroid injection among patients with different spinal pathologies-related radicular pain.

AIMS: This study aims to investigate the effectiveness of transforaminal epidural steroid injection (TFESI) in patients with lumbar radicular pain or radiculopathy caused by different spinal pathologies. METHODS: One hundred and seventy seven patients who underwent single transforaminal epidural steroid injection were included in the study group and divided into 3 subgroups (central spinal stenosis + lateral recess stenosis, foraminal stenosis, lumbar disc herniation) according to existing spinal pathology. Patients' visuel analogue scale (VAS) measures and Oswestry Disability Index (ODI) scores were recorded and the patients who give favourable response to treatment were called respondents and who were not called as non-respondents. Subgroups were compared statistically at the end of 12 months. RESULTS: Sixty patients (33.9%) were considered as respondents and 117 patients (66.1%) were non-respondents in the entire study group. Patients with foraminal stenosis included the vast majority of the respondents and showed better results of pain relief as opposed to patients of other groups at the end of 12 months (P < 0.001). CONCLUSION: TFESI was an effective treatment modality for pain relief and functional improvement in patients with foraminal stenosis. However, it could not produce the same results in patients with central spinal stenosis and lumbar disc herniations.

Does facet tropism negatively affect the response to transforaminal epidural steroid injections? A prospective clinical study.

OBJECTIVE: To examine the impact of the presence of facet tropism on the results of transforaminal epidural steroid injection for unilateral radicular pain induced by lumbar disc herniation. MATERIALS AND METHODS: We included 112 patients diagnosed with unilateral, single-level lumbar disc herniation-induced radicular pain. Injection was planned at relevant levels. The patients were assessed using the Numerical Rating Scale, the Modified Oswestry Disability Index, and the Beck Depression Inventory before the injection and at hour 1, week 3, and month 3 after the injection. Presence of facet tropism was assessed by measuring the facet angles in the L3-4, L4-5, and L5-S1 segments of lumbar MRI T2 sequence axial section. RESULTS: A significant decrease in the Numerical Rating Scale and an increase in the Modified Oswestry Disability Index scores were detected at all follow-ups in groups comprising 39 patients with and 61 without facet tropism (p < 0.05). On comparison, improvement in clinical parameters at week 3 and month 3 in the group without facet tropism was greater (p < 0.05). As treatment success is considered to be a ≥ 50% reduction in the Numerical Rating Scale scores, 55.2% of the patients attained treatment success at month 3. Further, although the treatment success rate in the group with facet tropism was 34.2%, it was 69% in that without facet tropism (p < 0.05). CONCLUSION: Facet tropism correlates with less success of transforaminal epidural steroid injection; therefore, facet tropism may be a worthwhile measurement in a discussion with patients of the benefits of the procedure.

Role of Magnetic Resonance Imaging in Ascertaining the Success of Transforaminal Epidural Steroid Injection for Lumbar Radicular Pain.

Objective: To explore the outcome differences of lumbar transforaminal epidural steroid injection (TFESI) according to magnetic resonance imaging (MRI) findings in patients with lumbar radicular pain. Design: Retrospective study. Setting: Single university-based interventional pain management unit. Patients: Fifty-nine patients who had lumbar radicular pain with a recent lumbar MRI and three-month follow-up were included. Methods: MRI findings were reviewed for the following items: herniation type (bulging, protrusion, extrusion), herniation location (central, subarticular, foraminal, extraforaminal), high intensity zone (HIZ), and nerve root impingement (NRI). Pain severity was evaluated using a visual analogue scale (VAS) at time of before injection, then two weeks and three months after. Results: Pain scores improved significantly in each group ( P < 0.05) at all time points, but there were no statistically significant differences in improvements according to type or location of disc herniation. Pain scores were significantly lower in patients with HIZ at the second week and in patients with NRI at the third month ( P < 0.05). Conclusions: TFESI was an effective treatment method in patients with radicular pain, irrespective of the type or location of disc herniation. However, greater improvement in pain may be expected at the second week in patients with HIZ and at the third month in patients with NRI.

New Optimal Needle Entry Angle for Cervical Transforaminal Epidural Steroid Injections: A Retrospective Study.

Objective: A cervical epidural steroid injection is one of the most commonly performed interventions to manage chronic neck pain and cervical radiculopathy. Despite its many severe complications, cervical transforaminal epidural steroid injection (CTFESI) is a clinically necessary modality for managing neck pain and cervical radiculopathy. We aimed in this study to find a safer optimal needle entry angle to decrease the chance of an accidental vertebral artery (VA) puncture even with a proper needle entry angle and to visualize the target of the needle tip. Methods: This retrospective study included 312 patients with neck pain or cervical radiculopathy who had undergone magnetic resonance imaging scans for diagnosis and treatment. The first line was drawn from the midpoint of the two articular pillars and passed through the exact midline of the spinous process. The second line was drawn parallel to the ventral lamina line (conventional transforaminal approach line, CTAL). The third line was drawn parallel to the ventral margin at the midpoint of the superior articular process's ventral border (new transforaminal approach line, NTAL). The angle of intersection between the midline and CTAL versus with NTAL were measured from both sides (right and left) at C5-6, C6-7, and C7-T1 levels. Also, the distance of CTAL and NTAL from VA were measured from both sides at each level. We examined whether the CTAL and NTAL would penetrate the ipsilateral VA, internal carotid artery (ICA), and internal jugular vein (IJV). Results: There were significant differences between CTAL and NTAL angles at all levels (P < 0.001). There were significant differences between the distance of CTAL and NTAL from VA at all levels (P < 0.001). There were also significant differences between the observed frequency of CTAL and NTAL that would penetrate the major ipsilateral vessel (VA, ICA, and IJV) on all levels and sides (P < 0.001~0.030). Conclusion: The angle of NTAL (approximately 70°) is safer than the angle of CTAL (approximately 50°) when considering vascular injuries to vessels, such as the VA, ICA, and IJV.

Lumbar Transforaminal Epidural Steroid Injections: Incidental Extraspinal Findings on Planning Imaging.

OBJECTIVE: Planning imaging performed during CT-guided procedures may occasionally contain important incidental findings. The purpose of this study was to identify and characterize by clinical relevance the extraspinal findings detected on planning imaging for CT-guided lumbar transforaminal epidural steroid injections (TFESIs). MATERIALS AND METHODS: Four radiologists retrospectively evaluated the planning scout views and CT studies for 488 consecutive CT-guided lumbar TFESIs performed in 400 patients over a 1-year period. Incidental extraspinal findings were identified and used to characterize patients by the need for follow-up using the CT Colonography Reporting and Data System (C-RADS), a classification scheme originally developed to characterize incidental findings on CT colonography. Patients with C-RADS E4 findings have potentially important findings that should be communicated to the referring physician; patients with C-RADS E3 findings have findings that are likely unimportant, but workup may be indicated. All previously unknown C-RADS E3 and E4 findings discovered in the course of this research were reported to referring physicians for appropriate patient follow-up. RESULTS: Ten of 400 (2.5%) patients were classified as C-RADS E4; the most common C-RADS E4 finding was vascular aneurysm or stenosis (4/400, 1.0%). Thirteen of 400 (3.3%) patients were classified as C-RADS E3; the most common C-RADS E3 finding was hepatomegaly (4/400, 1.0%). Of 22 patients with C-RADS E3 and E4 findings unknown to clinicians, the finding for only one (4.5%) was communicated to clinicians at the time of the procedure. CONCLUSION: Clinically important incidental extraspinal findings were identified in 5.8% of patients on the planning imaging performed for CT-guided lumbar TFESIs. Communication of clinically important findings was poor (4.5%).

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial.

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Optimal angle of needle insertion for fluoroscopy-guided transforaminal epidural injection of L5.

BACKGROUND: Unlike other sites, there is difficulty in performing TFESI at the L5-S1 level because the iliac crest is an obstacle to needle placement. OBJECTIVE: The objective of this study was to identify the optimal angle of fluoroscopy for insertion and advancement of a needle during L5 TEFSI. METHODS: We conducted an observational study of patients undergoing fluoroscopy-guided L5 TFESI in the prone position. A total of 80 patients (40 men and 40 women) with radiating pain of lower limbs were enrolled. During TFESI, we measured the angle at which the L5 vertebral body forms a rectangular shape and compared men and women. Then, we measured area of safe triangle in tilting angle of fluoroscopy from 15° to 35° and compared men and women. RESULTS: The mean cephalocaudal angle, where the vertebral body takes the shape of a rectangle, was 11.0° in men and 13.9° in women (P = 0.007). In men, the triangular area was maximal at 18.3 mm² with an oblique view angle of 25°. In women, the area was maximal at 23.6 mm² with an oblique view angle of 30°. At an oblique view angle of 30° and 35°, the area was significantly greater in women (P < 0.05). CONCLUSION: When TFESI is performed at the L5 region in the prone position, placement of fluoroscopy at a cephalocaudal angle of 11.0° and an oblique angle of 25° in men and cephalocaudal angle of 13.9° and an oblique angle of 30° in women would be most reasonable.