Interlaminar versus transforaminal epidural steroids for the treatment of lumbar radicular pain: A randomized, blinded, prospective outcome study (original) (raw)
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Anesthesiology and Pain Medicine, 2015
Background: Epidural steroid injection (ESI), including transforaminal (TF) epidural injections and interlaminar (IL) epidural steroid injections are commonly performed procedures for the management of lumbosacral radicular pain. Parasagittal interlaminar (PIL) approach could enable higher ventral epidural spread, with fewer complications than TF. Objectives: This study aims to compare the effectiveness of PIL and TF ESI in relieving the pain and disability of patients with lumbosacral pain. Patients and Methods: This prospective study enrolled 64 patients, aged between 18 to 75 years, with a diagnosis of low back pain and unilateral lumbosacral radicular pain. The patients were randomized to receive fluoroscopically guided epidural injection, through either the PIL or TF approach. Patients were evaluated for effective pain relief [numerical rating scale (NRS) < 3] by 0-10 numeric rating scale (NRS) and functional improvement by the Oswestry Disability Index (ODI). Results: Effective pain relief [numeric rating scale (NRS) < 3] was observed in 77.3% (95% CI: 67-90.5%) of patients in PIL group and 74.2% (95% CI: 62.4-89.4%) of patients in the TF group (P = 0.34), at 4 weeks. Mean NRS score was not significantly different between the PIL group compared to the TF group, at 4 weeks (P = 0.19). Number of patients with improved disability (measured by ODI < 20%) was not significantly different in PIL group (78% of cases) compared to the TF group (76% of cases), at 4 weeks (P = 0.21). There were no adverse effects observed in any of our patients. Conclusions: The PIL epidural injection is as effective as TF epidural injection in improving pain and functional status, in patients with chronic lumbosacral low back pain, due to disc degeneration.
The Korean Journal of Pain
Background: We aimed to compare interlaminar epidural steroid injections (ILESI) and bilateral transforaminal epidural steroid injections (TFESI) on pain intensity, functional status, depression, walking distance, and the neuropathic component in patients with lumbar central spinal stenosis (LCSS). Methods: The patients were divided into either the ILESI or the bilateral TFESI groups. Prime outcome measures include the numerical rating scale (NRS), Oswestry disability index (ODI), Beck depression inventory (BDI), and pain-free walking distance. The douleur neuropathique en 4 questions score was used as a secondary outcome measure. Results: A total of 72 patients were finally included. NRS, ODI, and BDI scores showed a significant decline in both groups in all follow-ups. Third-month NRS scores were significantly lower in the ILESI group (P = 0.047). The percentages of decrease in the ODI and BDI scores between the baseline and the third week and third month were significantly higher in the ILESI group (P = 0.017, P = 0.001 and P = 0.048, P = 0.030, respectively). Pain-free walking distance percentages from the baseline to the third week and third month were significantly higher in the ILESI group (P = 0.036, P < 0.001). The proportion of patients with neuropathic pain in the bilateral TFESI group significantly decreased in the third week compared to the baseline (P = 0.020). Conclusions: Both ILESI and TFESI are reliable treatment options for LCSS. ILESI might be preferred because of easier application and more effectiveness. However, TFESI might be a better option in patients with more prominent neuropathic pain.
Annals of International medical and Dental Research, 2017
It is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. radiculopathy secondary to disc herniation resolves spontaneously in 23% to 48% of patients, 5% to 15% of patients undergo surgery, resulting in a strain on the health care system and subsequently, the economy. [6-9] Various conservative, nonsurgical modalities for treating lumbar disc herniation or radicular pain exist, including epidural injections. Data from the Spine Patient Outcomes Research Trial (SPORT) evaluation reported the clinical and cost effectiveness of lumbar disc herniation ABSTRACT Background: Transforaminal epidural steroid injections (TFESI) and interlaminar epidural steroid injections (ILESI) are commonly performed procedures for the management of unilateral lumbosacral radicular pain (LSRP) due to intervertebral disc herniations. Unilateral LSRP is thought to originate from inflammation in the proximity of a damaged intervertebral disc or a narrowed neuralforamen that irritates an exiting spinal nerve root. Thus corticosteroids are commonly used to reduce inflammation in the epidural space. The purported advantage of TFESI over ILESI is attributed to enhanced deposition of medication in closest proximity to the pain generators found in the ventral epidural space and hence reaching the targeted pain generators with a smaller dose of medication. Data from multiple studies and systematic reviews of the published data support the utility of TFESI and have shown that lumbar TFESI are effective for reducing pain, improving functionality, preventing spine surgery and for treating radiculopathic pain. Methods: In a prospective study, 60 patients with low back pain were randomly allocated to one of the two groups of 30 patients each. In Group IL(interlaminar approach), with the patient in lateral position, under strict aseptic precautions, 18G Tuohy needle is placed by loss of resistance technique and confirmed using iohexol dye and 80 mg (2 mL) of methyprednisolone with 2 mL of normal saline is injected. In group TF(transforaminal approach), with the patient in prone position, under strict aseptic precautions, 23 G Quinke needle is placed in epidural space under C-arm guidance and confirmed by using Iohexol dye and 80 mg (2 mL) of methyprednisolone with 2 mL of normal saline is injected. Patient monitored for 15 mins after the procedure. Pain relief assessed by using Numerical Rating Scale(NRS), Verbal Rating Scale(VRS), Straight Leg Raising Test(SLRT) etc. Results: In Group IL, NRS decreased from 7.77±1.2 (pre-procedure) to 4.73±1.1 and 4.27±1.5 at the end of 2nd and 3rd week respectively. In Group TF, NRS decreased from 7.8±1.3 (pre-procedure) to 2.77±1.7 and 2.63±1.7 at the end of 2nd and 3rd week respectively. This difference in NRS was statistically significant both at the end of 2nd week and 3rd week with a P value of 0.001 with Group TF having better pain relief. There was no statistically significant difference among the 2 groups with respect to SLRT, improvement in walking tolerance, reduction in analgesic use and reversal of paraesthesia at the end of 3rd week. Conclusion: Epidural steroid injection by transforaminal route provides better subjective pain relief in the short term.
INTRODUCTION Lower back pain is one of the most common after headache. Along with lower back pain, radiating pain or radicular pain down to the lower limb is a widespread clinical problem that need be addressed precisely. Almost 30% of patients who develop lower back pain usually will suffer from radicular pain at one point of time. More than 50% of the patients with radiculopathy and sciatica have disturbances in performing activities of daily living and difficulty at work, leading to loss of work hours. The most common cause of lumbosacral radiculopathy in all the age group is intervertebral disc prolapse, and almost 10% to 15% of these patients eventually may require surgery due to their persistent symptoms, interference with daily activity, and neurological deficit. 1 However, majority of patients with lumbosacral radiculopathy have uneventful recovery with conservative management. The conservative management is wide and typically includes bed rest during acute ABSTRACT Background: Low back pain is a common entity with a lifetime prevalence of 65 to 80 percent in general population, and usually disrupts work, social activity and activity of daily living. The purpose of our study was to evaluate the results of interlaminar epidural steroid injection versus caudal steroid injection for patients of lower back pain with radiculopathy, due to disc prolapse or disc degeneration in terms of pain relief and complications. Methods: A total of 272 subjects having low back pain with radicular leg pain and MRI evidence of single or double level disc prolapse were chosen. Out of 272, patients were randomly assigned to two group; the first group having 131 patients and second group having 141 patients. The first group received caudal steroid injection, and second group received interlaminar epidural steroid under fluoroscopy control. Follow up for both groups was at 1 week, 6 weeks, and 12 weeks. Results: The change in pain scores were rated as mild, moderate and excellent. The interlaminar epidural steroid injection fared excellent in earlier follow up, getting to moderate at 12 weeks' time. The caudal steroid injection produced moderate relief in early phase at 12 weeks' time. Conclusions: The caudal steroid injection is cost effective, easy to administer and is having much less complications as compared to interlaminar steroid injection. Both these procedures are safe, well tolerated procedures, and can be performed as outpatient procedures
Pain Medicine, 2014
Objective. To assess whether the immediate anesthetic response of pain relief (sensory blockade) or weakness (motor blockade) after lumbar transforaminal epidural steroid injection (TFESI) is associated with longer term effectiveness in pain relief and functional recovery. Design. Retrospective observational study. Setting. Single academic radiology practice. Subjects. Three thousand six hundred forty-five lumbar TFESIs performed on 2,634 subjects. Methods. Subjects completed a pain numerical rating scale (NRS, 0-10) and Roland-Morris disability questionnaire (R-M) prior to and immediately after TFESI (NRS) and at 2 weeks and 2 months follow-up. Successful pain relief was ≥50% NRS reduction; functional success was ≥40% R-M reduction. Post-procedure motor weakness was recorded. Logistic regression models assessed association of immediate post-procedure NRS response, and NRS or R-M response at 2 weeks, with successful outcomes at 2 months. C-index assessed model discrimination; values closer to 1.0 indicated better discrimination. Results. Immediate NRS response was weakly associated with 2-month outcomes (C-index = 0.58). NRS and R-M responses at 2 weeks were more strongly associated with the 2-month response (C-indices 0.77, 0.80, respectively). Post-procedure motor blockade had little association with successful 2-month NRS or R-M outcomes (C-indices 0.51, 0.50, respectively). Patients that responded at 2 weeks were more likely to be responders at 2 months than those who were non-responders at 2 weeks (odds ratio = 6.49, confidence interval 5.38, 7.84). Conclusion. Immediate post-TFESI pain relief does not strongly predict longer term effectiveness in pain relief or functional recovery. Response in pain relief or functional recovery at 2 weeks is more strongly associated with 2-month outcomes.
Systematic review of therapeutic lumbar transforaminal epidural steroid injections
Pain physician
Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. The transforaminal route to the lumbar epidural space for steroid injection has gained rapid and widespread acceptance for the treatment of lumbar and leg pain. However, there are few well-designed randomized, controlled studies to determine the effectiveness of epidural injections. The role and value of transforaminal lumbar epidural steroid injections is still questioned. A systematic review of transforaminal epidural injection therapy for low back and lower extremity pain. To evaluate the effect of transforaminal lumbar epidural steroid injections in managing lumbar (low-back) and sciatica (leg) pain. The available literature of lumbar transforaminal epidural injections in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utiliz...
Epidural steroids in the management of chronic spinal pain: a systematic review
Pain Physician, 2007
BACKGROUND: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of epidural injections. Consequently, debate continues as to the value of epidural steroid injections in managing spinal pain.OBJECTIVE: To evaluate the effect of various types of epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic spinal pain (axial and radicular) in the neck and low back regions.STUDY DESIGN: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used.METHODS: Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term).OUTCOME MEASURES: The primary outcome measure is pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer.RESULTS: In managing lumbar radicular pain with interlaminar lumbar epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal epidural steroid injections in managing lumbar radicular pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal epidural steroid injections in managing cervical nerve root pain is moderate. The evidence is moderate in managing lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic pain of lumbar radiculopathy and postlumbar laminectomy syndrome.CONCLUSION: There is moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal epidural steroid injections is moderate for long-term improvement in managing nerve root pain. The evidence for caudal epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain.
Background: Prolapsed Lumbar Intervertebral Disc (PLID) is one of the most common health problems worldwide, as well as in our country, and is one of the potential causes of temporary disability, morbidity, and reasoning of absence at workplaces. Objective: To find out the outcome of C-arm guided transforaminal and caudal epidural steroid injection for low back pain with radiculopathy due to PLID. Methodology: This was a randomized clinical trial conducted among purposively selected 54 patients with PLID with radiculopathy as per selection criteria, attending the Department of Physical Medicine & Rehabilitation in BSMMU, Dhaka, from March 2020 to February 2021. Patients (N=54) were randomly allocated into two groups; patients in group A (n=26) were treated with C-arm guided transforaminal and caudal epidural steroid injection with conservative treatment, and patients in group B (n=28) were treated with conservative treatment only. All patients were followed up in 1 st week, 1 st month, and 3 rd month. Results: The mean age of the participants in group A and group B were 40.88 (± 8.70) and 43.00 (± 11.54) years, respectively. In group A, 9 (34.6%) were housewives, 4 (15.4%) were manual workers, while in group B, 10 (35.7%) were housewives, and 8 (28.6%) were manual workers. In group A, 21 (80.8%) had three disc involvement, while in group B, 19 (67.9%) had three discs involvement, where L4-5-disc involvement was most common in both groups. There was no significant statistical difference between the groups regarding VAS scores at baseline (p=0.235), 1st week (p=0.164), and 1st month (p=0.125). The VAS score was significantly reduced in group A compared to group B at 3 rd month (p=0.001). The ODI score was significantly reduced in group A compared to group B at 1st week (p=0.034), 1 st month (p=0.016), and at 3 rd month (p=0.001). Conclusion: C-arm guided transforaminal and caudal Epidural Steroid Injection significantly improves pain and functional outcomes of patients with radiculopathy due to PLID. Long-term, large scale and multicenter research studies are required to establish the outcome and effectiveness of this procedure.