The Incidence of Intradiscal, Intrathecal, and Intravascular Flow During the Performance of Retrodiscal (Infraneural) Approach for Lumbar Transforaminal Epidural Steroid Injections

Levi, David; Horn, Scott; Corcoran, Sarah

doi:10.1093/pm/pnv067

Cited by 33 publications

(26 citation statements)

References 20 publications

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“…A number of concerns have been raised regarding the side effects of TFEI such as lower-limb paraplegia resulting from intravascular penetration or embolic infarct (41). The incidence of pain or discomfort related to nerve root damage and intradiscal penetrations was also higher in TFEI than in ILEI, probably because of the needle approach (4,18,42). Taken together, ILEI could be a suitable alternative to TFEI or the first choice of treatment.…”

Section: Discussionmentioning

confidence: 92%

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Lee

2018

Pain Phys

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Background: Epidural injection (EI) is used to treat back or radicular pain from lumbosacral disc herniation (LDH). Although several reports have stated that the transforaminal approach in EI (TFEI) has an advantage in target specificity and yields better clinical efficacy than the interlaminar approach in EI (ILEI), other studies have indicated that the clinical efficacy of ILEI was not inferior to that of TFEI and that ILEI also has the ability to spread medication into the ventral space to a degree similar to that of TFEI. There has been controversy about whether TFEI is superior to ILEI in clinical efficacy. Objectives: This systematic review and meta-analysis aimed to investigate whether TFEI is more useful than ILEI for achieving clinical outcomes in patients with LDH. Study design: A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCT). Methods: A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From those found fulfilling the search criteria, manuscripts that compared the clinical efficacy of steroids and control agents, such as local anesthetics or saline, in terms of pain control and functional improvement were included in this study. Exclusion criteria included a previous history of lumbosacral surgery, nonspecific low back pain, severe spinal stenosis, and severe disc degeneration. After reviewing titles, abstracts, and the full text of 6,711 studies; 12 studies were included in the qualitative synthesis. Data including pain scores, functional scores, and follow-up period were extracted from 10 studies and analyzed using a random effects model to obtain effect size and its statistical significance. The quality and level of evidence were analyzed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: In terms of pain control, TFEI showed significantly better short-term (2 weeks to 1 month) outcomes and slightly favorable long-term (4 - 6 month) outcomes, but without significance, in comparison with ILEI. In terms of functional improvement, TFEI also showed favorable short- and long-term outcomes, but without significance, in comparison with ILEI. TFEI had target specificity, required no additional cost and resources, and had equal applicability to ILEI. However, TFEI was more associated with a higher frequency of discomfort or adverse events during the procedure. Overall, better results were reported with TFEI over ILEI, but with low-grade evidence due to the inconsistency and imprecision of the selected studies. Limitation: Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies. Conclusions: Based on low-grade evidence, TFEI showed significantly better short-term pain control and slightly favorable outcomes in long-term pain reduction and short- and long-term functional improvement in comparison with ILEI. Key words: Epidural injection, interlaminar, transforaminal, meta-analysis, systemic review, pain, function

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Section: Discussionmentioning

confidence: 92%

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Lee

2018

Pain Phys

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“…To avoid intra‐arterial injection some schools recommend approaching the inferior part of the neuroforamen (especially for injections above L3), as the artery of Adamkiewicz rarely traverses this part of the foramen The approach is therefore in accordance with the Kambin triangle (Figure ) and is also referred to as the retrodiscal technique. As the endpoint is located immediately posterior of the disc, it provides a higher chance for accidental disc punctures . It is also unclear to which extent a correct epidural contrast flow can be achieved with this approach.…”

Section: Which Route For Administering Epidural Corticoids?mentioning

confidence: 99%

“…As the endpoint is located immediately posterior of the disc, it provides a higher chance for accidental disc punctures. 176 It is also unclear to which extent a correct epidural contrast flow can be achieved with this approach.…”

Section: Conclusion Of the Work Groupmentioning

confidence: 99%

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

et al. 2018

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“…Using the RD approach, the needle tip may unintentionally be placed too far ventrally and enter the IVD. Levi et al (38) performed 257 RD TF injections, and demonstrated a 4.7% rate of intradiscal injection. Needle entry into the IVD may be of concern for several reasons.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Epidural Spreading Patterns and Clinical Outcomes of Transforaminal Epidural Steroid Injection with High-Volume Injectate via the Subpedicular Versus the Retrodiscal Approach

Park

2018

Pain Phys

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Background: The effect of transforaminal epidural steroid injection (TFESI) appears to be influenced by the volume of the injected material because there is a positive correlation between injection volume and extent of pain relief. Objectives: The purpose of this study was to examine how many vertebral segments are covered by the subpedicular (SP) approach and the retrodiscal (RD) approach and to compare the clinical outcomes of the 2 approaches in TFESI with high-volume injectates. Study Design: A randomized, active control trial. Setting: Medical University centers. Methods: Fifty patients were randomly assigned to either the SP group or the RD group. TFESI was performed with high-volume injectates. A total of 9 mL injectate was divided into 3 injections (0.5 mL, 2.5 mL, and 6 mL) given at 10-second intervals. The primary outcome measure was injectate distribution. The spreading patterns were described as unilateral, bilateral, ventral, or dorsal. Ventral or dorsal flow was also described as being cephalad or caudad, respectively. The secondary outcome measures were pain relief and reduction of functional disability at 4 weeks after the procedure. Results: The total numbers of vertebral segments and median levels of contrast spread from the injection site were not significantly different between the 2 groups. However, in 3 mL of injectate, the injectate spread showed more extensive bilateral distribution in the RD group. At 4 weeks after treatment, both groups demonstrated statistically significant pain relief and improvement in functional status. No significant differences were observed between the 2 groups. Limitations: We enrolled only a small number of patients and did not analyze long-term outcomes. Patients with severe spinal stenosis or herniated nucleus pulposus were included. Slightly different methods were used in the 2 groups to determine the number of levels at which the injectate was spread. Conclusions: Epidural spreading patterns and clinical outcomes of lumbar TFESI with highvolume injectate were not significantly different between the SP approach and the RD approach. Institutional Review Board (IRB) approval: Institutional Review Board of Ewha Womans University Hospital (EUMC 2015-05-003-003). Clinical trials registration number: Clinical Research Information Service (CRIS, registration number: KCT0002288; RCT URL: https://cris.nih.go.kr/cris/ search/search_result_st01.jsp?seq=7309) Key words: Epidural injections, epidural space, low back pain, radiating pain, disability evaluation, steroids, local anesthetics, intervertebral disc disease, spinal stenosis

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The Incidence of Intradiscal, Intrathecal, and Intravascular Flow During the Performance of Retrodiscal (Infraneural) Approach for Lumbar Transforaminal Epidural Steroid Injections

Cited by 33 publications

References 20 publications

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group

Comparison of Epidural Spreading Patterns and Clinical Outcomes of Transforaminal Epidural Steroid Injection with High-Volume Injectate via the Subpedicular Versus the Retrodiscal Approach

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