Epidural Contrast Flow Patterns of Transforaminal Epidural Steroid Injections Stratified by Commonly Used Final Needle-Tip Position

Desai, Mehul; Shah, Binit; Sayal, Puneet

doi:10.1111/j.1526-4637.2011.01119.x

Cited by 34 publications

(35 citation statements)

References 19 publications

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“…The TF approach has several theoretical advantages over other routes of injection in that it is the most target-specific, carries a lower risk of inadvertent dural puncture, 91 and is associated with a greater incidence of ventral epidural spread, especially with placement of the needle in the anterior foramen. 92 However, TF ESIs are also associated with an increased risk profile compared with the caudal and IL approaches. In addition, although there is some evidence for better efficacy compared with caudal and IL ESI, 93 their efficacy in neuropathic spinal pain (NSP) still remains controversial.…”

Section: Transforaminalmentioning

confidence: 99%

Epidural Steroids

Cohen¹,

Bicket

Jamison

et al. 2013

Regional Anesthesia and Pain Medicine

300

114

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Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.

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Section: Transforaminalmentioning

confidence: 99%

Epidural Steroids

Cohen¹,

Bicket

Jamison

et al. 2013

Regional Anesthesia and Pain Medicine

300

114

View full text Add to dashboard Cite

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“…Candido et al [2] found the PIL approach to be superior to TFESI with respect to ventral contrast flow and effectiveness. We find their conclusion to be in error, however, as the authors in fact compared PIL with the superoposterior intervertebral foraminal placement of a transforaminal injection [1]. Furthermore, although the injection was performed at the most lateral part of the interlaminar space, the depth of spreading into the ventral epidural space anterior to the nerve root and the dural sac by this route may be inconsistent [3]; and in rare instances, the PIL technique may result in nerve injury [19].…”

Section: Discussionmentioning

confidence: 99%

“…But although the radiologic target advocated for transforaminal injections corresponds to the superoanterior region of the foramen, needle placement anterior to the "safe triangle" region may be complicated if the foramen is distorted by stenosis, and in far lateral disc herniations, spondylolisthesis and scoliosis. In these situations, the spinal nerve location in the intervertebral foramen is elevated, and the needle must avoid the anterior position [1]. …”

Section: Introductionmentioning

confidence: 99%

Fluoroscopic analysis of lumbar epidural contrast spread after retrograde interlaminar ventral epidural injection (RIVEI)

Jeong

Shim

Woo

2013

Korean J Anesthesiol

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BackgroundRetrograde interlaminar ventral epidural injection (RIVEI) may hypothetically be more effective if the catheter is placed at the ventrocaudal aspect of the exiting nerve. We tested that hypothesis by measuring ventral and dorsal epidural contrast flow during RIVEI.MethodsTo perform RIVEI, a 17 G Tuohy needle was inserted to access the epidural space. A 19 G epidural catheter was inserted and advanced through the needle, passing in a caudal direction to the lower aspect of the contralateral pedicle. Fluoroscopic images were recorded at 1.5 ml increments of contrast. Based on the images of contrast dispersal, the extent of contrast spreading was assessed in 82 patients.ResultsAll 82 patients (100%) injected with 3.0 ml contrast medium demonstrated ventral epidural spreading. Mean spreading level from the catheter tip was 2.21 ± 0.93 with 3.0 ml of contrast. Spreading to the superior aspect of the supra-adjacent intervertebral disc was observed in 67/82 (81.7%) of RIVEIs with 3.0 ml of contrast injected into the ventral epidural space. We found that 3.0 ml of contrast reached the inferior aspect of the infra-adjacent intervertebral disc in 95.1% (78/82) of RIVEIs performed.ConclusionsOur findings imply that a one-level RIVEI may be sufficient in situations where a two-level injection would currently be used.

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“…Patients with a peripheralizing pain response are treated with TESIs. A possible explanation for a peripheralizing pain response is that radicular pain is aggravated during the MDT assessment process due to irritation of an inflamed nerve root [12][13][14]. Following this, it seems reasonable to treat peripheralizers firstly with TESIs in order to target the presumably inflamed nerve root, and secondly with physical therapy, if necessary.…”

Section: Introductionmentioning

confidence: 99%

Transforaminal epidural steroid injections influence Mechanical Diagnosis and Therapy (MDT) pain response classification in candidates for lumbar herniated disc surgery

Helvoirt

Apeldoorn

Knol

et al. 2016

BMR

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Abstract. STUDY DESIGN: Prospective cohort study. BACKGROUND: Although lumbar radiculopathy is regarded as a specific diagnosis, the most effective treatment strategy is unclear. Commonly used treatments include transforaminal epidural steroid injections (TESIs) and Mechanical Diagnosis & Therapy (MDT), but no studies have investigated the effectiveness of this combination. MDT differentiates pain centralization (C) from non-centralization (NC), which indicates good vs. poor prognostic validity respectively. OBJECTIVE: The main aims were 1) to determine changes in Mechanical Diagnosis and Therapy (MDT) pain response classifications after transforaminal epidural steroid injections (TESIs) in candidates for lumbar herniated disc surgery and 2) to evaluate differences in short and long term outcomes for patients with different pain response classifications. METHODS: Candidates for lumbar herniated disc surgery were assessed with a MDT protocol and their pain response classified as centralizing or peripheralizing. For this study,only patients were eligible who showed a peripheralizing pain response at intake. All patients then received TESIs and were reassessed and classified using the MDT protocol, into groups according to pain response (resolved, centralizing, peripheralizing with less pain and peripheralising with severe pain). After receiving targeted treatment based on pain response after TESIs, ranging from advice, MDT or surgery, follow-up assessments were completed at discharge and at 12 months. The primary outcomes were disability (Roland-Morris Disability Questionnaire [RMDQ] for Sciatica), pain severity in leg (visual analogue scale [VAS], 0-100) and global perceived effect (GPE). Linear mixed-models were used to determine between-groups differences in outcome. RESULTS: A total of 77 patients with lumbar disc herniation and peripheralizing symptoms were included. Patients received an average of 2 (SD 0.7) TESIs. After TESIs, 17 patients (22%) were classified as peripheralizing with continuing severe pain. H. van Helvoirt et al. / Transforaminal epidural steroid injections influence MDT pain response classificationThese patients underwent surgery and were not further evaluated. Eleven (14%) patients were classified as resolved, 37 (48%) as centralizing with significant less pain, and 12 (16%) as peripheralizing with significant less pain. None of these patients underwent surgery. Resolved and centralizer subgroups had better outcomes in terms of VAS and RMDQ than the non-operated peripheralizers at discharge and at 12 months. The succes rates (GPE) for the resolved, centralizing, and peripheralizing with less pain patients were 100%, 100% and 33% respectively at short term, and 100%, 92% and 50% respectively at long term. CONCLUSION: After TESIs, a peripheralizing pain pattern changed to resolved or centralizing in 62% of the patients. For the non-operated patients, those with a centralising pattern after TESIs reported better pain and disability outcomes than those with peripheralizing pattern at short ...

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Epidural Contrast Flow Patterns of Transforaminal Epidural Steroid Injections Stratified by Commonly Used Final Needle-Tip Position

Cited by 34 publications

References 19 publications

Epidural Steroids

Epidural Steroids

Fluoroscopic analysis of lumbar epidural contrast spread after retrograde interlaminar ventral epidural injection (RIVEI)

Transforaminal epidural steroid injections influence Mechanical Diagnosis and Therapy (MDT) pain response classification in candidates for lumbar herniated disc surgery

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