A Prospective Comparison of CT-Epidurogram Between Th1-Transforaminal Epidural Injection and Th1/2-Parasagittal Interlaminar Epidural Injection for Cervical Upper Limb Pain.

BACKGROUND: Cervical epidural injections for treating neck and upper limb pain are performed by 2 methods: transforaminal and interlaminar. Many serious complications caused by inadvertent intravascular injection have been reported with the use of cervical transforaminal epidural steroid injection through the anterior-lateral approach. Despite international practical guidelines that have been proposed, cervical transforaminal epidural injection is still less recommended than cervical interlaminar epidural injection. OBJECTIVES: The objective of this study is to introduce Th1-transforaminal epidural injection (Th1-TFEI) through the posterior-lateral approach, compare the injectate spread in Th1-TFEI with that of Th1/2-parasaggital interlaminar epidural injection (Th1/2-pILEI), and clarify the clinical characteristics of Th1-TFEI. STUDY DESIGN: This research involved a prospective study of 30 patients receiving both Th1-TFEI and Th1/2-pILEI. METHODS: Thirty patients with unilateral upper limb pain were enrolled for this prospective study. Th1-TFEI and Th1/2-pILEI were administered on each case in random order under fluoroscopy, and computed tomographic (CT) epidurograms were compared. Changes in circulatory dynamics, presence of Horner's syndrome, changes in the Numerical Rating Scale (NRS-11), and adverse events were investigated. RESULTS: Patients included 15 men and 15 women and included 24 cases of cervical spine disease and 6 cases with other upper limb pain. The Th1-TFEI group had significantly higher rates of "Th1 root filling" (100%), "ventral spread" (70.0%), and "lateral limitation" (26.7%) compared to the Th1/2-pILEI group. In the Th1-TFEI group, cephalad spread averaged 2.97 vertebral bodies, reaching approximately up to C6. The Th1/2-pILEI group had an average of 4.76 vertebral bodies, approximately up to C4. The 2 groups showed significant differences in cephalad spread. Horner's syndrome appeared in the Th1-TFEI group at a rate of 56.7%, significantly higher than that in the Th1/2-pILEI group at 17.2%. The presence of Horner's syndrome showed significant correlations with "ventral spread" and "spread up to C6." There were no significant differences in NRS-11 improvement and changes in circulatory dynamics between the groups. There were no major complications. LIMITATIONS: The components of injectate were standardized; however, the needle gauge numbers were varied. In addition, interpretation of the CT-epidurogram was not blinded. The sample size was small; therefore, multivariate analysis was not possible. CONCLUSIONS: CT-epidurogram comparison revealed that Th1/2-pILEI was not localized on the injection side, and there was better dorsal spread - although ventral spread was small. Contrarily, Th1-TFEI was localized on the injection side, and better ventral spread was shown while cephalad spread was limited. We expected the addition of a sympathetic block effect suggested by the Horner's syndrome as well as the merits of the ventral spread. However, short-term clinical effects were equal to those of Th1/2 pILEI. In future research, we need to standardize the diseases to include and to increase the number of cases to enable evaluation of clinical effectiveness. KEY WORDS: Epidural, cervical, transforaminal, interlaminar, fluoroscopy, CT-epidurogram, dorsal, ventral, cephalad, Horner's syndrome.

Transforaminal vs Interlaminar Epidural Steroid Injection for Acute-Phase Shingles: A Randomized, Prospective Trial.

BACKGROUND: The acute phase of shingles is characterized by severe pain, and one of the complications of shingles known as postherpetic neuralgia (PHN) is associated with prolonged pain. Although factors predicting the development of PHN, as well as its preventative measures, have been investigated, there is no single treatment effective for PHN. Some studies showed effectiveness of epidural injection to alleviate pain associated with acute-phase shingles. In these studies, epidural injection was performed by interlaminar (IL) approach. However, transforaminal (TF) approach may be more effective as it enables injection of steroids and local anesthetics closer to the dorsal root ganglion where inflammation primarily occurs. There have not been any studies comparing the analgesic effects of epidural injection approaches for pain associated with acute-phase shingles. OBJECTIVE: We compared the analgesic effects of IL and TF epidural injection approaches for pain associated with acute-phase shingles. STUDY DESIGN: We conducted a randomized prospective trial. SETTING: Nara Medical University Hospital, Department of Anesthesiology. METHODS: Forty patients with acute-phase shingles were randomly assigned to receive epidural steroid injections by TF or IL approaches. Patients were evaluated at the baseline, as well as at 1 month and 3 months after the treatment using the VAS and SF-36 scores. Patients with VAS score of over 40 at the 3-month follow-up were considered as having PHN, and the number of patients with PHN was compared between the IL and TF groups. RESULTS: Except the mental component of the SF-36 score and severity of skin rash, patient characteristics were not significantly different between the groups. VAS scores at 1 and 3-month follow-up were significantly lower than those at the baseline, and there was no difference between the groups. All SF-36 scores were not significantly different between groups at 1- and 3-month. There was no significant difference in the occurrence of PHN between the groups. LIMITATIONS: We had a small sample size that did not reach the number of patients needed by the power analysis in the study. Then, our follow-up period of 3 months was relatively short. CONCLUSIONS: VAS scores, the SF-36 RCS and MCS scores improved in both groups, however, there was no difference in the analgesic effects of the IL and TF epidural steroid injections at 1 and 3 months for acute-phase shingles patients. KEY WORDS: Shingles epidural steroid injection interlaminar approach; transforaminal approach, fluoroscopic, postherpetic neuralgia, VAS, SF-36.

Transforaminal epidural blood patch for intractable spontaneous cerebrospinal fluid leak: a case report.

BACKGROUND: Epidural blood patch (EBP) is a recognized treatment for spontaneous cerebrospinal fluid leak (SCFL) and is typically administered by the interlaminar approach. Here, we report a case of a patient in whom SCFL failed to resolve after three applications of interlaminar EBPs before finally being successfully treated with transforaminal EBP. CASE PRESENTATION: We report a case of a 41-year-old female with a definitive diagnosis of SCFL according to computed tomography (CT) myelography. A fluoroscopy-guided interlaminar EBP was applied three times without resolution of her orthostatic headache. A second myelography was therefore performed demonstrating a leak point on the ventral side of the dura mater. To close the ruptured ventral dura mater, it was necessary to fill the ventral epidural space with blood. Therefore, transforaminal EBP was performed. On spinal CT performed immediately after treatment, the ventral epidural space was observed to be filled with injected blood. Her headache improved the following day, and her symptoms completely subsided after 5 days. CONCLUSION: Transforaminal epidural blood patch is appropriate for patients with intractable cerebrospinal fluid leak. Patients with cerebrospinal fluid leakage due to rupture of the ventral side of the dura mater may be particularly good candidates for this procedure.

Evaluation on a clinical course of subdural hematoma in patients undergoing epidural blood patch for spontaneous cerebrospinal fluid leak.

OBJECTIVE: Subdural hematoma (SDH) is a frequent complication of spontaneous intracranial hypotension (SIH), in which epidural blood patch (EBP) may be applied as a treatment to stop cerebrospinal fluid (CSF) leak. However, a clinical course of SDH in SIH patients has not been sufficiently evaluated. We retrospectively evaluated the temporal relationships between EBP and SDH in the patients with SIH. METHODS: Twenty-nine consecutive patients, diagnosed as SIH, were studied. Clinical records and images were retrospectively evaluated. When orthostatic headache continued for 2 weeks regardless of conservative treatment, EBP was performed under fluoroscopy. RESULTS: We detected 13(45%) cases of SDH (mean age 44 years, 8 males and 5 females). In 6 patients, SDHs disappeared after effective EBP, i.e., after the disappearance of orthostatic headache. In 3 patients, SDHs were enlarged or recurred after effective EBP, and in 4 patients, SDHs were first detected after effective EBP. CONCLUSION: The knowledge of the presence of these types of SDH (enlarged or recurred or detected after EBP) may deserve clinical attention.

[Diagnosis and treatment of chronic pain by pain clinicians].

Pain is classified into physical and psychological pain. Physical pain is nociceptive, inflammatory, or neuropathic. Pain can be categorized into acute or chronic pain depending on the duration of pain and mechanism of onset. Acute pain heals as the underlying cause is resolved and includes naturally curable nociceptive and potentially curable neuropathic pain. Chronic pain is caused by incurable conditions or requires a long time to heal and is persistent: it includes chronic nociceptive pain, established neuropathic pain, and psychogenic pain. The therapeutic strategies for pain depend on the underlying pathological conditions: (1) For nociceptive pain, analgesics, narcotic analgesics, and nerve block are indicated. (2) For neuropathic pain, supplementary analgesics, but not analgesics, are indicated, and some narcotic analgesics are also effective: the recommended supplementary analgesics include calcium channel alpha-2-delta ligands, tricyclic antidepressants (TCAs), and serotonin-noradrenaline reuptake inhibitors (SNRIs). (3) For psychogenic pain, analgesics and nerve block are not indicated, except in the setting of a placebo effect: in paticular, narcotic analgesics should not be used. Psychological therapy, tranquilizer administration, cognitive behavior therapy, and patient education are indicated for this kind of pain.

Comparison between computed tomography-myelography and radioisotope-cisternography findings in whiplash-associated disorders suspected to be caused by traumatic cerebrospinal fluid leak.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: To investigate the traumatic cerebrospinal fluid (CSF) leak in whiplash-associated disorders (WADs) by comparing radioisotope-cisternography (RIC) and computed tomography (CT)-myelography (CTM) findings. SUMMARY OF BACKGROUND DATA: WAD has been considered to be caused by traumatic CSF leak and termed as traumatic CSF hypovolemia. Several studies have reported that CSF leak was detected on RIC in the lumbosacral region of patients with WAD. However, recent evidence has indicated that RIC sometimes creates false-positive results by detecting nerve roots or cysts as CSF leak, whereas the appearance of contrast medium in the epidural space on CTM demonstrates CSF leak directly. So far there have been no data to compare the RIC and CTM findings in patients with WAD. METHODS: RIC and CTM were performed on 36 patients with WAD, and the RIC and CTM findings were compared. In RIC, 37 MBq (111)In was injected, and paraspinal RI accumulation was evaluated as a direct sign of CSF leak. In CTM, 10 mL of iohexiol (240 mg I/mL) was infused via lumbar puncture, and multislice CT scan of the whole spine was acquired. Epidural collection of contrast medium, nerve root morphology, and cystic structures were investigated. RESULTS: Paraspinal RI accumulation was observed in 19 patients on RIC, and it was located in the lumbosacral region in 18 patients. In contrast, no epidural collection was observed on CTM. CTM findings revealed that root sleeves and cystic structures were observed at the locations in which paraspinal RI accumulation was noted on RIC. CONCLUSION: The results in this study indicated that traumatic CSF leak was not observed on CTM in patients with WAD, in whom CSF leak was suspected on RIC.

Comparison of computed tomography myelography and radioisotope cisternography to detect cerebrospinal fluid leakage in spontaneous intracranial hypotension.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: To compare the usefulness of radioisotope cisternography (RIC) and computed tomography myelography (CTM) for the detection of cerebrospinal fluid (CSF) leakage in spontaneous intracranial hypotension (SIH). SUMMARY OF BACKGROUND DATA: CSF leakage sites have been generally identified by RIC in patients with SIH. Although a number of reports have recently indicated the usefulness of CTM, whether RIC or CTM more reliably detects leakage sites has not been decided because the 2 tests have not been directly compared. METHODS: Both RIC and CTM were performed, and the findings were compared in 12 patients with SIH strictly meeting the second edition of the International Classification of Headache Disorders diagnostic criteria. : On RIC, the detection rate of leakage including indirect signs, an early vesicular radioisotope (RI) accumulation and delayed ascent of the RI to the cerebral convexity, was observed in 100%, but that of the direct sign, paraspinal RI accumulation, was in 8 patients (67%). On CTM, the epidural collection of intraspinally administered contrast medium was demonstrated in all patients (100%), and the collection site was located in the cervical and thoracic vertebral regions in most cases. When RIC and CTM findings were collated, paraspinal accumulation in the cervical and thoracic regions on RIC corresponded to the entire or a part of the findings on CTM. In contrast, in 4 of 5 patients with paraspinal accumulation in the lumbosacral region, epidural collection was not noted in this region on CTM. CONCLUSION: In patients with SIH, epidural collection on CTM may more accurately demonstrate CSF leakage compared with paraspinal RI accumulation on RIC.

Fluoroscopically guided epidural blood patch in patients with postdural puncture headache after spinal and epidural anesthesia.

Postdural puncture headache (PDPH) is one of the major complications after spinal and epidural anesthesia. An epidural blood patch (EBP) may be applied when PDPH persists regardless of conservative treatment. We describe the results of management including fluoroscopically guided EBP in a series of patients with moderate to severe PDPH. From January 2007 to December 2009, PDPH developed in 15 of 3,381 patients (0.44%) who received epidural or spinal anesthesia: 5 (0.21%) after general anesthesia combined with epidural anesthesia, 8 (0.81%) after spinal anesthesia, and 2 (3.14%) after combined spinal and epidural anesthesia. Of 15 patients, PDPH was relieved without the EBP in 9 patients and 6 patients required the EBP. EBP was performed under fluoroscopy in a prone position; a 4:1 mixture of autologous blood and contrast medium was injected to cover the site of dural puncture. The success rate of fluoroscopically guided EBP was 100% with a mean blood volume of 7.2 ml. No complications were associated with EBP except for a mild backache. Fluoroscopically guided EBP may be successfully and safely performed to treat persistent PDPH with a relatively small volume of blood for epidural injection.

Fluoroscopically guided epidural blood patch with subsequent spinal CT scans in the treatment of spontaneous cerebrospinal fluid hypovolemia.

OBJECT: Recent evidence has indicated that the efficacy of the epidural blood patch (EBP) in the treatment of spontaneous CSF hypovolemia (SCH) is still limited. Therefore, further improvement of the EBP technique is an important clinical challenge. The authors describe a series of cases of SCH treated with fluoroscopically guided placement of an EBP and followed up with subsequent spinal CT scans. METHODS: Thirteen patients with SCH that was proven on CT myelography studies underwent epidural puncture under fluoroscopic guidance and received an injection of a mixture of contrast medium and autologous blood. Contrast medium was injected to cover the area of CSF leakage during EBP guided by fluoroscopy, and the spread of the blood was subsequently evaluated using spinal CT scanning. If the amount of blood injected was insufficient to cover the leakage area, a second EBP was performed at a later date. RESULTS: At the first EBP procedure, a mixture with a mean volume of 9.4 ml (range 3-20 ml) was injected, and subsequent spinal CT scans revealed contrast enhancement in the desired epidural space in 12 of 13 patients. In 2 patients, a second EBP was required because of insufficient coverage of the leakage area or delayed recurrence of headache. In all patients, a complete recovery from orthostatic headache was obtained after the last EBP. CONCLUSIONS: The results indicated that fluoroscopically guided EBP and subsequent spinal CT scans may provide a highly effective therapy in patients with SCH proven on CT myelography studies.

[Case of cerebrospinal fluid hypovolemia possibly due to acceleration of cerebrospinal fluid absorption].

The authors present a case of a 31-year-old man suffering from intractable cerebrospinal fluid hypovolemia (CSFH), in whom autologous epidural blood patch at the cervical, thoracolumbal, and sacral sites was not effective. Repeated radionuclide cisternography reproducibly demonstrated "early accumulation of radioactivity in the bladder", "cystic accumulation of radioactivity at the sacral site" and "less activity than expected over the cerebral convexities"; but computerized tomography myelography did not demonstrate CSF leakage but detected a sacral cyst. These repeated radionuclide cisternography findings suggested unusually rapid uptake of tracer by the circulation but did not always CSF leakage. The finding of strong accumulation of radioactivity in the sacral cyst might mean the opposite CSF flow against normal caudal-cranial flow. The formation of this abnormal cranial-caudal CSF flow could be produced with CSF leakage or abnormal absorption at the caudal site, where the cyst existed in the patient. Therefore, it is not unreasonable to suppose that the sacral cyst appeared to be responsible for development of CSFH in the patient. The possibility of acceleration of cerebrospinal fluid absorption in the sacral cyst was proposed for the cause of CSFH if CSF leakage was denied.

Inexpensive phantom for fluoroscopy guided nerve block training*.

OBJECTIVE: Regional anesthesia simulation manikins with phantom skeletal structures are commercially available. Unfortunately, they are quite expensive. This article introduces our handmade, low cost, phantom for training of nerve block with fluoroscopic guidance. MATERIALS: The phantom consisted of artificial bone models to resemble human lumbar vertebrae with disks, covered with 5-7 sheets of self-adhesive sponge. Posteriorly, mobility between sheets was retained in order to deflect needles and provide practice of redirecting needles. CONCLUSIONS: Although it might lack radiographic fidelity, our inexpensive phantom can be used for basic training of nerve block with fluoroscopic guidance.