Convolutional neural network algorithm trained on lumbar spine radiographs to predict outcomes of transforaminal epidural steroid injection for lumbosacral radicular pain from spinal stenosis.

Little is known about the therapeutic outcomes of transforaminal epidural steroid injection (TFESI) in patients with lumbosacral radicular pain due to lumbar spinal stenosis (LSS). Using lumbar spine radiographs as input data, we trained a convolutional neural network (CNN) to predict therapeutic outcomes after lumbar TFESI in patients with lumbosacral radicular pain caused by LSS. We retrospectively recruited 193 patients for this study. The lumbar spine radiographs included anteroposterior, lateral, and bilateral (left and right) oblique views. We cut each lumbar spine radiograph image into a square shape that included the vertebra corresponding to the level at which the TFESI was performed and the vertebrae juxta below and above that level. Output data were divided into "favorable outcome" (≥ 50% reduction in the numeric rating scale [NRS] score at 2 months post-TFESI) and "poor outcome" (< 50% reduction in the NRS score at 2 months post-TFESI). Using these input and output data, we developed a CNN model for predicting TFESI outcomes. The area under the curve of our model was 0.920. Its accuracy was 87.2%. Our CNN model has an excellent capacity for predicting therapeutic outcomes after lumbar TFESI in patients with lumbosacral radicular pain induced by LSS.

Relationships between the Spinal Dural Pulsations and the Short-Term Efficacy of Lumbar Epidural Steroid Injection.

Background: Lumbar spinal stenosis (LSS) causes low back pain, leg pain, numbness in the leg, and neurogenic intermittent claudication. Epidural steroid injection (ESI) has been used for treating spinal stenosis symptoms. We hypothesized that dural pulsation was variable for lumbar spinal stenosis. In cases of the presence of dural pulsation, the pain relief after the ESI was better than in the absence of dural pulsation. This study aimed at investigating the relationships between the presence or absence of spinal dural pulsations and the efficacy of ESI. Methods: A total of 71 patients were enrolled in this prospective study. Prior to the ESI, the dural pulsation was measured using a 5-1 MHz array ultrasound transducer. The visual analogue scale (VAS) score was measured pre-ESI and 2 weeks post-ESI and 4 weeks post-ESI. At 4 weeks post-ESI, dural pulsation was rechecked. Results: The VAS scores improved after the ESI procedure regardless of the presence or absence of dural pulsation. There was a correlation between the pulsation of the dura and post-ESI VAS scores. However, VAS was not significantly different for different grades of stenosis. Conclusion: The ESI was effective in patients with spinal stenosis in short-term follow-up. Dural pulsation of the spinal cord was a positive predictive factor for the ESI effect, but the grade of spinal stenosis severity had no effect on the effectiveness of ESI.

Effectiveness of Corticosteroid Therapy in Enhancing Early Postoperative Recovery in Lumbar Spinal Stenosis Patients: A Retrospective Study.

BACKGROUND The degree of postoperative symptom improvement in patients with lumbar spinal stenosis (LSS) is crucial to their postoperative rehabilitation process and functional exercise. Corticosteroids have certain anti-inflammatory effects. This study aimed to explore whether small doses of corticosteroids would improve postoperative neurological symptoms in patients with lumbar spinal stenosis. MATERIAL AND METHODS Patients with lumbar spinal stenosis who underwent open surgery were divided into a corticosteroid therapy group (CTG) and a non-corticosteroid therapy group (NCTG). They were followed up for 24 months after surgery. The numeric rating scale (NRS) for leg pain (NRS-LP) and leg numbness (NRS-LN), Oswestry Disability Index (ODI) scores, and Short Form Health Survey (SF-36) scores of the 2 groups were compared at different time points to evaluate the therapeutic effect. RESULTS Of the 232 eligible patients enrolled, 128 received corticosteroids and 104 did not. At the 1-month postoperative follow-up, patients in the CTG had significantly lower NRS-LP and NRS-LN scores than those in the NCTG (P=0.017; P=0.043). At the 3-month follow-up, the NRS-LP and ODI scores of patients in the CTG were significantly lower than those of the NCTG (P=0.015; P=0.027), and SF-36 scores were significantly higher than that of the NCTG (P=0.012). At the 6-month follow-up, the SF-36 scores of patients in the CTG was significantly higher than that of the NCTG (P=0.008). CONCLUSIONS Small doses of corticosteroid therapy for postoperative lumbar spinal stenosis reduced symptoms and improved quality of life scores after surgery. However, it had little long-term impact on final patient outcomes.

The effectiveness of vitamin D3 supplementation in improving functional outcome of non-surgically treated symptomatic lumbar spinal stenosis: Randomized controlled clinical trial - Pilot study.

BACKGROUND: Although vitamin D is one of the essential nutrients associated with musculoskeletal system function, there is no standard treatment method for vitamin D deficiency. This study aimed to investigate the effects of vitamin D supplementation on the improvement in symptoms, functional recovery of the spine, and changes in the quality of life in patients with spinal stenosis. METHODS: In this prospective study, patients with spinal stenosis and serum 25-hydroxy vitamin D levels < 10 ng/mL were randomly assigned to a supplementation group (Group S) and a non-supplementation group (Group NS): 26 participants in Group S (16 females and 10 males) and 25 in Group NS (15 females and 10 males). The degree of lower back pain in both groups was assessed using the visual analog scale; spine function was assessed using the Oswestry disability index and Roland-Morris disability questionnaire; and patient quality of life was assessed using the 36-item short form health survey. We compared and analyzed the values that were measured at baseline, between 4 and 6 weeks (V1), 10 and 12 weeks (V2), and 22 and 26 weeks (V3). RESULTS: No statistically significant difference was observed in lower back pain, spine function, or quality of life between both groups at baseline. In terms of lower back pain in V1, Group S scored 4.15 ±â€…3.12, while Group NS scored 5.64 ±â€…1.85 (P = .045). In V2, Group S scored 3.15 ±â€…2.38, while Group NS scored 4.52 ±â€…1.87 (P = .027). Moreover, in V3, Group S scored 3.58 ±â€…1.65, while Group NS scored 4.60 ±â€…1.68 (P = .033), indicating a statistically significant improvement in each period. CONCLUSION: If a vitamin D deficiency that does not require surgical treatment exists in patients with lumbar spinal stenosis, high-dose vitamin D injections can improve lower back pain, which is the main symptom of lumbar spinal stenosis, as well as the functional outcomes of the spine and quality of life.

Effect of systemic lidocaine on postoperative quality of recovery, the gastrointestinal function, inflammatory cytokines of lumbar spinal stenosis surgery: a randomized trial.

Surgery is one of the most frequent and effective intervention strategies for lumbar spinal stenosis, however, one-third of patients are not satisfied with postoperative outcomes. It is not clear whether perioperative systemic lidocaine could accelerate the early postoperative quality of recovery in patients undergoing lumbar spinal stenosis surgery. 66 patients were enrolled in this trial. Lidocaine or placebo was administered at a loading dose of 1.5 mg/kg for 10 min and then infused at 2.0 mg/kg/hour till the end of surgery. Continued infusion by postoperative patient-controlled intravenous analgesia with a dose of 40 mg/hour. The primary outcome was the quality of recovery. Secondary outcomes included the time of the patient's first flatus, catheter removal time, underground time from the end of the surgery, pain score, levels of inflammatory factors (IL-6, IL-10, TNF-α), postoperative nausea and vomiting (PONV), sufentanil rescues, patients' satisfaction scores, and complications of lidocaine. Eventually, 56 patients were in the final analysis with similar age, Body Mass Index (BMI), duration of surgery and anesthesia, and median QoR-15 score (a development and Psychometric Evaluation of a Postoperative Quality of Recovery Score). The difference in median QoR-15 score in placebo versus lidocaine patients was statistically significant (IQR, 106 (104-108) versus 114 (108.25-119.25), P < 0.001). The Numeric Rating Scale (NRS) score at the 12th hour, median sufentanil rescue consumption, IL-6, tumor necrosis factor-alpha (TNF-α) of patients treatment with lidocaine were lower. Nevertheless, patients given lidocaine had high satisfaction scores. Suggesting that lidocaine enhanced the postoperative quality of recovery, met early postoperative gastrointestinal function recovery, provided superior pain relief, lessened inflammatory cytokines, etc., indicating it may be a useful intervention to aid recovery following lumbar spinal stenosis surgery.

Epidural Injection of Harpagoside for the Recovery of Rats with Lumbar Spinal Stenosis.

Epidural administration is the leading therapeutic option for the management of pain associated with lumbar spinal stenosis (LSS), which is characterized by compression of the nerve root due to narrowing of the spinal canal. Corticosteroids are effective in alleviating LSS-related pain but can lead to complications with long-term use. Recent studies have focused on identifying promising medications administered epidurally to affected spinal regions. In this study, we aimed to investigate the effectiveness of harpagoside (HAS) as an epidural medication in rats with LSS. HAS at various concentrations was effective for neuroprotection against ferrous sulfate damage and consequent promotion of axonal outgrowth in primary spinal cord neurons. When two concentrations of HAS (100 and 200 µg/kg) were administered to the rat LSS model via the epidural space once a day for 4 weeks, the inflammatory responses around the silicone block used for LSS were substantially reduced. Consistently, pain-related factors were significantly suppressed by the epidural administration of HAS. The motor functions of rats with LSS significantly improved. These findings suggest that targeted delivery of HAS directly to the affected area via epidural injection holds promise as a potential treatment option for the recovery of patients with LSS.

Efficacy of Aceclofenac and Ilaprazole Combination Therapy versus Celecoxib Monotherapy for Treating NSAID-Induced Dyspepsia in Lumbar Spinal Stenosis Patients.

Background and Objectives: Dyspepsia is a common adverse event associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with lumbar spinal stenosis. Although proton pump and cyclooxygenase-2 inhibitors are potential treatment options, the optimal strategy remains unclear. This study aimed to compare the efficacy and safety of combination therapy with aceclofenac and ilaprazole versus celecoxib monotherapy for the treatment of dyspepsia caused by NSAID use in patients with lumbar spinal stenosis. Materials and Methods: This prospective, double-blind, randomized, actively controlled study was conducted at Seoul National University Bundang Hospital in South Korea from July 2020 to September 2021. The participants were randomized into one of two treatment groups: celecoxib monotherapy (control group) and combination therapy with aceclofenac and ilaprazole (test group). The primary efficacy endpoint was the mean change in the Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ) scores from baseline to treatment week 8. The secondary efficacy endpoint was the mean change in Short-Form-12 (SF-12) scores from baseline (week 0) to treatment week 8. Results: The study enrolled 140 patients who were randomly assigned to receive combination therapy with aceclofenac and, ilaprazole or celecoxib. In the per protocol set, the mean change in SF-LDQ scores from week 0 to week 8 was -0.51 ± 4.78 and 1.85 ± 6.70 in the combination therapy and celecoxib group, respectively (p = 0.054). SF-12 scores did not differ significantly between the two groups. Adverse events were reported in both groups, but there was no significant difference in incidence. Conclusions: Combination therapy with aceclofenac and ilaprazole can be a treatment option for NSAID-induced dyspepsia in some situations.

Changes in pain scores and walking distance after transforaminal epidural steroid injection in patients with lumbar foraminal spinal stenosis.

Transforaminal epidural steroid injections (TFESI) are widely used in patients with lumbar foraminal spinal stenosis. Previous studies have evaluated the effects of TFESI on lumbar foraminal spinal stenosis using only pain scores. However, no study has evaluated the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis. This study aimed to assess the effect of TFESI on pain scores and walking distance in patients with lumbar foraminal spinal stenosis stratified according to disease severity. This retrospective study reviewed the medical records of patients who received TFESI for lumbar foraminal spinal stenosis. A total of 128 patients were divided into the moderate and severe groups based on the extent of fat obliteration and the presence of nerve root compression. A significant decrease in the numeric rating scale (NRS) scores was observed in the moderate and severe groups compared with the corresponding baseline values 4 weeks after TFESI; however, the NRS pain scores were lower in the moderate group than those in the severe group. In addition, the proportion of patients who experienced pain reduction (≥50%) was higher in the moderate group than that in the severe group. The moderate and severe groups showed a significant increase in walking distance compared with the baseline values 4 weeks after the treatment. However, the walking distance values did not differ significantly between the moderate and severe groups. Furthermore, the degree of satisfaction was higher in the moderate group than that in the severe group. Lumbar TFESI may reduce pain scores and increase walking distance in patients with moderate or severe lumbar foraminal spinal stenosis. Patients with moderate foraminal stenosis had better pain relief outcomes than those with severe foraminal stenosis.

Efficacy of ultrasound guided caudal epidural steroid injection with or without ozone in patients with lumbosacral canal stenosis; a randomized clinical controlled trial.

BACKGROUND: Lumbosacral canal stenosis is known as the most common cause of back surgery with several complications. Selecting a minimally invasive treatment with high efficacy in such patients is necessary. This study was designed to evaluate the effectiveness of ozone therapy in combination with caudal epidural steroid in patients with lumbar spinal stenosis. METHODS: A double-blind randomized clinical trial was conducted on 50 patients with lumbar spinal stenosis allocated into two study groups. Under ultrasound guidance, the first group received 80 mg of triamcinolone hexavalent with 4 mL of Marcaine 0.5% and 6 mL of distilled water to the caudal epidural space. The second group received an injection similar to the first group, combined with 10 mL of ozone (O2-O3) gas at a concentration of 10 µg/cc. The patients were followed at baseline, one, and six months after injection with clinical outcomes measures using Visual Analog Scale (VAS), Walking Distance (WD) and Oswestry Disability Index (ODI). RESULTS: The mean age of subjects, 30 males (60%) and 20 females (40%), was reported as 64.51 ± 7.19 years old. Reduction of pain intensity based on VAS score was statistically significant in both groups at follow-up periods (P < 0.001). The VAS changes in the first month and sixth months showed no significant difference between the two groups (P = 0.28 and P = 0.33, respectively). The improvement in disability index (ODI) in both types of treatment during follow-up was significant (P < 0.0001), and there was no difference between the two treatment groups in one month and six months (P = 0.48 and P = 0.88, respectively). As for walking distance, the improvement process with both types of treatment during follow-up periods was significant (P < 0.001). However, after one and six months of treatment, the rate of improvement in patients' walking distance in the caudal epidural steroid injection plus ozone group was significantly higher than in the epidural steroid group (p = 0.026 and p = 0.017, respectively). CONCLUSIONS: In this study, the results of VAS and ODI outcomes showed that caudal epidural steroid injection combined with ozone has no advantage over caudal epidural steroid injection alone. Interestingly, our results demonstrated that the group receiving caudal epidural steroid injection plus ozone scored significantly higher on the walking distance index than the group receiving caudal epidural steroid alone. TRIAL REGISTRATION: IRCT IRCT20090704002117N2 (registration date: 07/08/2019).

Recanalization of external iliac artery occlusion in a patient with spinal stenosis using medications: a case report.

BACKGROUND: Iliac artery occlusion accompanied by spinal canal stenosis is rare. All reported cases were treated with endovascular stenting for iliac artery occlusion. We report the first case of external iliac artery occlusion accompanied by spinal stenosis, which was successfully treated with conservative treatment. CASE PRESENTATION: A 66-year-old man with lower extremity pain and claudication visited the outpatient spine clinic. He complained of a tingling sensation in the L5 dermatome of the right leg and L4 dermatome of the left leg. Magnetic resonance imaging showed central stenosis in at the L4-5 and L5-S1 levels, and lateral recess stenosis at the L5-S1 level. The patient's symptoms were ambiguous with mixed neurological claudication and vascular claudication. Computed tomography of the lower extremity artery showed complete occlusion in the right external iliac artery. Conservative treatment with clopidogrel and beraprost sodium was performed. After treatment, his symptoms gradually improved. Clopidogrel and beraprost sodium were continued for 4 years. Follow-up computed tomography at 4 years showed recanalization of the right external iliac artery occlusion. CONCLUSIONS: We describe a rare case of external iliac artery occlusion and spinal stenosis. External iliac artery occlusion may be successfully treated only with conservative treatment using medication.

Efficacy of surgical treatment on polypharmacy of elderly patients with lumbar spinal canal stenosis: retrospective exploratory research.

BACKGROUND: Polypharmacy is a growing public health problem occurring in all healthcare settings worldwide. Elderly patients with lumbar spinal canal stenosis (LSS) who manifest low back and neuropathic pain and have a high frequency of comorbidity are predicted to take many drugs. However, no studies have reported polypharmacy in elderly patients with LSS. Thus, we aimed to review the polypharmacy among elderly LSS patients with elective surgeries and examine how the surgical treatment reduces the polypharmacy. METHODS: We retrospectively enrolled all the patients aged ≥ 65 years who underwent spinal surgery for LSS between April 2020 and March 2021. The prescribed drugs of participants were directly checked by pharmacists in the outpatient department preoperatively and 6-month and 1-year postoperatively. The baseline characteristics were collected beside the patient-based outcomes including Roland-Morris Disability Questionnaire, Zurich Claudication Questionnaire, and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The cutoff number of drugs for polypharmacy was defined as 6. The prescription drugs were divided into 9 categories: drugs for neuropsychiatric, cardiovascular, respiratory, digestive, endocrine metabolic, and urinary renal diseases; blood products; pain relief medication; and others. RESULTS: A total of 102 cases were finally analyzed, with a follow-up rate of 78.0%. Of the participants, the preoperative polypharmacy prevalence was 66.7%. The number of drugs 6-month and 1-year postoperatively was significantly less than the preoperative one. The proportions of polypharmacy at 6 months and 1 year after surgery significantly decreased to 57.8% and 55.9%, respectively. When the prescribed drugs were divided into 9 categories, the number of drugs for pain relief and digestive diseases was significantly reduced after surgery. The multi-variable analysis revealed that a higher score in the psychological disorder of JOABPEQ was associated with 3 or more drugs decreased 1-year postoperatively (OR, 2.5; 95% CI: 1.0-6.1). CONCLUSION: Polypharmacy prevalence was high among elderly LSS patients indicated for lumbar spinal surgery. Additionally, our data showed that lumbar spinal surgery was effective in reducing polypharmacy among elderly LSS patients. Finally, the multi-variable analysis indicated that better psychological condition was associated with the reduction of prescribed drugs after lumbar spinal surgery.

Treatment With Opioids Is Not Associated With Poor Outcomes Among Older Adults With Lumbar Spinal Stenosis Receiving Epidural Injections.

STUDY DESIGN: Secondary analysis of a randomized controlled trial. OBJECTIVE: To assess how baseline treatment with opioids is associated with pain and function in older adults with lumbar spinal stenosis who receive epidural injections. SUMMARY OF BACKGROUND DATA: Data were obtained from the Lumbar Epidural Steroid injections for Spinal Stenosis trial, a double-blind, multisite, randomized controlled trial. METHODS: Baseline treatment with opioids was assessed from electronic medical record prescription pharmacy data or from health utilization records collected from patients. We calculated adjusted changes in back pain numerical rating scale, leg pain numerical rating scale, and back-related disability (Roland Morris Disability Questionnaire scores) from baseline to three weeks and to six weeks among patients treated and not treated with opioids at baseline using generalized linear regression. RESULTS: Baseline treatment with opioids was not significantly associated with back pain intensity (adjusted difference in means at three weeks of follow-up between patients treated with opioids at baseline versus not [±95% CI, 0.1 (-0.7, 0.7)], leg pain intensity [-0.2 (-0.9, 0.4)], or back-related function [-0.8 (-2.1, 0.4)]. We found similar results at six weeks of follow-up. CONCLUSIONS: Among older adults with lumbar spinal stenosis who are receiving epidural injections, those treated with opioids at baseline had similar outcomes to those who were not.

Factors Associated with Treatment Success After Interlaminar Epidural Steroid Injection for Cervical Radicular Pain.

AIM: To investigate the demographic, clinical and radiological findings associated with treatment success after interlaminar epidural steroid injection (ILESI) in radicular pain induced by cervical disc herniation. MATERIAL AND METHODS: In this retrospective study, the data of patients who received cervical ILESI between January 2017 and June 2021 were screened. Of 223 patients, 92 with unilateral radicular neck pain due to cervical disc herniation were included. Demographic data, symptom duration, and numerical rating scale scores at baseline, at three weeks, three months, and six months after treatment were collected from the medical records of the patients. Disc herniation level, cervical axis, disc height, presence and degree of spinal canal and neural foraminal stenosis, vertebral endplate signal change, and definitive presence of uncovertebral and facet osteoarthritis were evaluated using cervical spine magnetic resonance imaging. Treatment success was determined as ?50% reduction in pain scores at six months compared to baseline. RESULTS: Data of 92 patients (27 men, 65 women) were included. The mean age was 50.82 ± 10.22 years, and the median symptom duration was 12 (4.25 to 20) months. At six months after ILESI, treatment was successful in 58 (58.7%) patients and unsuccessful in 34 (41.3%) patients. Multivariable logistic regression analysis was performed to identify the factors associated with treatment success at six months post-injection. In the final model, neural foraminal stenosis (non-severe vs. severe) and spinal canal stenosis (non-severe vs. severe) were significantly associated with the treatment success (OR=3.02, 95% CI=1.40?10.95, p=0.009; OR=5.31, 95% CI=1.77?15.85, p=0.003). CONCLUSION: Treatment success of cervical ILESI at six months is favorable. However, the presence of severe neural foraminal and spinal canal stenosis is associated with a reduced likelihood of treatment success.

Add-on Effect and Safety of Pharmacopuncture Therapy in the Treatment of Patients with Lumbar Spinal Stenosis.

Background: Recently, Korean Medicine treatment with pharmacopuncture therapy (PPT) has been increasingly used in clinical practice to improve symptoms in patients with lumbar spinal stenosis (LSS). The aim of this study is to evaluate the effectiveness and safety of PPT in addition to conventional Korean Medicine treatment (CKMT) for the treatment of patients with LSS, compared with CKMT alone. Methods: This study is designed as a pragmatic, randomized, two-armed, parallel, stratified (by sex), controlled pilot trial. Forty patients diagnosed with LSS will be randomly allocated to the PPT + CKMT group or the CKMT group. Patients in the two groups will receive treatment two times weekly for 5 weeks. The primary outcome will be the mean change in the 100-mm visual analog scale score from the baseline to the end of treatment (week 5). The secondary outcomes will include the clinically important difference, Zurich Claudication Questionnaire score, self-reported walking capacity, Modified-Modified Schober test, EuroQol 5-dimension 5-level questionnaire, and Patients' Global Impression of Change. Adverse events will be assessed at each visit. Discussion: The results of this study will provide meaningful data to evaluate the add-on effect and safety of PPT in the medical care of patients with LSS.

A comparison between effectiveness of gluteal trigger point and epidural steroid injection in lumbosacral canal stenosis patients: a randomized clinical trial.

BACKGROUND: Lumbosacral Spinal Stenosis (LSS) is a degenerative spine disease and a major cause of pain and disability, especially in geriatrics. Primary symptom control in patients with LSS includes conservative treatment and non-surgical methods. In this study, we aimed to compare the effect of steroid injection via epidural and gluteal trigger point techniques. METHODS: Patients aged 40-75 years old who had pain and other clinical signs of spinal stenosis in the last 6 months were included in our study and divided into two groups of gluteal trigger point (TP) or epidural steroid injection (ESI). The patients were evaluated based on the visual analog scale (VAS), Roland-Morris Disability Questionnaire (RDQ), Oswestry Disability Index (ODI), and the Quebec back pain disability scales during their pre-injection period and 2 weeks after follow-ups till 8 weeks. A P value of less than 0.05 was considered significant. RESULTS: A total of 44 patients were included in our study. The TP group had a significant decrease in comparison with their follow-ups; however, in the epidural group, the significant decrease was only observed compared to the pre-injection period and the scores did not have any significant decreases after the second week regarding the ODI, RQM, and VAS scales. The TP group demonstrated significantly higher scores of decreases of ODI and Quebec score compared to the epidural group at weeks 4 and 8. Regarding RQM, the TP groups demonstrated significantly higher scores of decreases compared to the epidural group at weeks 2, 4 and 8. (p < 0.001 p = 0.008, and p < 0.001, respectively). CONCLUSION: Both epidural and TP steroid injection significantly reduced the patients' pain and improved their QoL and function; however, more satisfactory results were observed in the TP group during the patients' follow-ups, while the epidural group demonstrated only statistically significant improvement during the short-term follow-up.

A new technique for controlling intractable pain in lumbar spinal stenosis using steroid injection to ligamentum flavum: A case series.

BACKGROUND: Lumbar spinal stenosis is a common degenerative disease that causes low back and lower-extremity pain that increases with age. The treatment of lumbar spinal stenosis is either conservative or surgical. ESI is a commonly performed conservative treatment, but evidence of its effectiveness in lumbar spinal stenosis is limited. CASE SERIES: We encountered the three patients with back pain and claudication due to lumbar spinal stenosis, which could not be controlled by conservative therapy including ESIs. Trimacinolone acetonide was injected into the patients' ligamentum flavum. All patients experienced dramatic improvement in their symptoms. CONCLUSIONS: Trimacinolone acetonide injection into the ligamentum flavum may be effective for lumbar spinal stenosis that does not improve with ESIs.

Predictive factors for favorable short-term response to interlaminar epidural block for cervical radiculopathy.

PURPOSE: We sought to identify clinical predictors of favorable short-term outcomes associated with cervical interlaminar epidural injection (CIEI). Previous studies investigating the predictive factors of CIEI efficacy have shown inconsistent results. Gaining information on the possible response determinants of CIEI is necessary for appropriate treatment selection and outcomes prediction in the treatment of cervical radiculopathy. METHODS: We analyzed the clinical data of 72 patients who received fluoroscopic-guided CIEI using the paramedian approach for cervical radiculopathy to identify the predictive factors for short-term outcomes of CIEI. Demographic characteristics, history of neck surgery, diagnosis, initial numeric rating score, duration of symptoms, Douleur Neuropathique 4 (DN4) questions, painDETECT questionnaire, neck disability index, and ventral epidural spread of contrast medium were assessed. Treatment success was defined as at least a 50% reduction in the numeric rating score after CIEI and was designated as a good response. RESULTS: The short-term success rate of CIEI for cervical radiculopathy was 55.56%. Multivariate logistic regression analysis established that spinal stenosis (odds ratio 0.183; P = 0.012), a longer duration of > 24 weeks of symptoms (odds ratio 0.206; P = 0.026), and combined positive results for the DN4 and painDETECT (odds ratio, 0.019; P = 0.008) decreased the odds ratio of a good response, 2-3 weeks after CIEI. CONCLUSIONS: CIEI provides a significant short-term outcome in patients with cervical radiculopathy. However, CIEI efficacy may be negatively affected in patients with spinal stenosis, the presence of a chronic state, and a possible neuropathic pain component.

Estimating individualized treatment effects using a risk-modeling approach: an application to epidural steroid injections for lumbar spinal stenosis.

ABSTRACT: Conventional "1-variable-at-a-time" analyses to identify treatment effect modifiers are often underpowered and prone to false-positive results. This study used a "risk-modeling" approach guided by the Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement framework: (1) developing and validating a multivariable model to estimate predicted future back-related functional limitations as measured by the Roland-Morris Disability Questionnaire (RMDQ) and (2) stratifying patients from a randomized controlled trial (RCT) of lumbar epidural steroid injections (LESIs) for the treatment of lumbar spinal stenosis into subgroups with different individualized treatment effects on RMDQ scores at the 3-week follow-up. Model development and validation were conducted in a cohort (n = 3259) randomly split into training and testing sets in a 4:1 ratio. The model was developed in the testing set using linear regression with least absolute shrinkage and selection regularization and 5-fold cross-validation. The model was then applied in the testing set and subsequently in patients receiving the control treatment in the RCT of LESI. R2 values in the training set, testing set, and RCT were 0.38, 0.32, and 0.34, respectively. There was statistically significant modification ( P = 0.03) of the LESI treatment effect according to predicted risk quartile, with clinically relevant LESI treatment effect point estimates in the 2 quartiles with greatest predicted risk (-3.7 and -3.3 RMDQ points) and no effect in the lowest 2 quartiles. A multivariable risk-modeling approach identified subgroups of patients with lumbar spinal stenosis with a clinically relevant treatment effect of LESI on back-related functional limitations.

Deep Learning Algorithm Trained on Lumbar Magnetic Resonance Imaging to Predict Outcomes of Transforaminal Epidural Steroid Injection for Chronic Lumbosacral Radicular Pain.

BACKGROUND: Transforaminal epidural steroid injections (TFESI) are widely used to alleviate lumbosacral radicular pain. Knowledge of the therapeutic outcomes of TFESI allows clinicians to elucidate therapeutic plans for managing lumbosacral radicular pain. Deep learning (DL) can outperform traditional machine learning techniques and learn from unstructured and perceptual data. A convolutional neural network (CNN) is a representative DL model. OBJECTIVES: We developed and investigated the accuracy of a CNN model for predicting therapeutic outcomes after TFESI for controlling chronic lumbosacral radicular pain using T2-weighted sagittal lumbar spine magnetic resonance (MR) images as input data. STUDY DESIGN: Imaging study using DL. SETTING: At the spine center of a university hospital. METHODS: We collected whole T2-weighted sagittal lumbar spine MR images from 503 patients with chronic lumbosacral radicular pain due to a herniated lumbar disc (HLD) and spinal stenosis. A "good outcome" was defined as a >= 50% reduction in the numeric rating scale (NRS-11) score at 2 months after TFESI vs the pretreatment NRS-11 score. A "poor outcome" was defined as a < 50% decrease in the NRS-11 score at 2 months after TFESI vs pretreatment. RESULTS: In the prediction of therapeutic outcomes after TFESI on the validation dataset, the area under the curve was 0.827. LIMITATIONS: Our study was limited in that we used a small amount of lumbar spine MR imaging data to train the CNN model. CONCLUSIONS: We demonstrated that a CNN model trained, using whole lumbar spine sagittal T2-weighted MR images, could help determine outcomes after TFESI in patients with chronic lumbosacral radicular pain due to an HLD or spinal stenosis.