The Lumbar Neural Foramen and Transforaminal Epidural Steroid Injections: An Anatomic Review With Key Safety Considerations in Planning the Percutaneous Approach

Mandell, Jacob; Czuczman, Gregory J.; Gaviola, Glenn C.; Ghazikhanian, Varand; Cho, Charles H.

doi:10.2214/ajr.16.17471

Cited by 53 publications

(49 citation statements)

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“…To reduce radiation exposure to the radiation, we used the anterior-posterior subpedicular approach at our centre. In another review article, Mandel and colleagues discuss the anatomy of the lumbar neural foramen and key considerations in planning TFESI [ 23 ]. The posterior lateral approach and Kambin’s triangle approach were discussed.…”

Section: Discussionmentioning

confidence: 99%

“…The posterior lateral approach and Kambin’s triangle approach were discussed. At our centre, we targeted the traditional safety triangle keeping the needle tip just inferior to the pedicle and superior, anterior and lateral to the exiting nerve [ 23 ]. Atluri and colleagues [ 24 ] have reviewed the literature and discussed cases of 10 cases of paralysis from TFESI due to injection in the radicular artery.…”

Section: Discussionmentioning

confidence: 99%

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Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal

et al. 2020

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Background The prevalence of low back pain with radiculopathy in general population varies from 9.9% to 25%, which can be due to bony narrowing of the lateral recess or due to prolapsed intervertebral disc. Transforaminal epidural injection of a mixture of long-acting anaesthetic (bupivacaine) and particulate steroids (depomedrol) has been a treatment modality in patients not responding to initial physiotherapy and neuropathic pain medications. Methods To analyze the effectiveness of transforaminal epidural steroid injection (TFESI) in the treatment of low back pain with radiculopathy, a retrospective case series evaluating the records of patients that received TFESI (1 mL 0.5% bupivacaine +1 ml/40 mg depomedrol) under C-arm guidance from January 2015 to December 2018 (3 years) at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), their lumbo-sacral MRI and the pre-procedure, 1-week and 3-month numeric pain rating scale, were analyzed. Successful treatment (reduction of pain scale by more than 50% of baseline at 3 months) in the patients with bony recess stenosis and those with prolapsed intervertebral disc was compared. Results Out of 67 patients that received TFESI, 35 (52.23%) could be followed up. The mean age was 55.8 ± 14.39 years and 51.3% were females. 68.57% had L5 and 20% had S1 radiculopathy. Bony recess stenosis was seen in the aged 40% and PIVD was the cause of radiculopathy in 60%. The median duration of radicular pain prior to intervention was 3 months. TFESI was effective as the mean numeric pain scale before injection was 8.97 ± 1.32 which reduced to 3.91 ± 3.23 (paired t test p value < 0.001) at 1 week post injection and 3.23 ± 3.34 (paired t test p value < 0.001) at 3 months post injection. Twenty-six of the 35 patients (75.29%) had more than 50% pain relief compared to baseline at 3 months and were satisfied. Nine patients continued to have pain; however, only one required a surgical intervention. The effectiveness of TFESI was not significantly different in different ages (Fisher’s exact test p value 0.182) and in different anatomic levels (Fisher’s exact test p value 0.241). Six out of eight patients with bony recess stenosis benefited as compared to 14 out of 19 patients with PIVD, though it was not statistically significant (Fischer’s exact test p value 0.688). There were no adverse events recorded. Conclusion TFESI is a safe and efficacious treatment modality in patients with radicular low back pain especially in aged patients in whom surgery under general anaesthesia is not free from risk.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal

et al. 2020

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“…6 The doubleoblique approach allows the safest passage (posterior and inferior) through the foramen. 7,8 In the aging spine, the anatomy of the foramen can, however, be modified by a bulging disc and/or osteophytes. Careful examination of the planning CT is therefore recommended before thermosensor insertion.…”

Section: Discussionmentioning

confidence: 99%

Transforaminal Insertion of a Thermocouple on the Posterior Vertebral Wall Combined with Hydrodissection during Lumbar Spinal Radiofrequency Ablation

Lecigne¹,

Garnon

Cazzato

et al. 2019

AJNR Am J Neuroradiol

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The purpose of the present article is to describe the technique of transforaminal insertion of an ultrathin thermosensor in the anterior epidural space in 13 patients treated by radiofrequency ablation. The mean time taken to position the thermosensor was 10.6 minutes (range, 5-38 minutes). Technical success was 93% (correct positioning in 13/14 levels). Additional hydrodissection was performed through the same access in 11 cases. No postoperative neural deficit was elicited in any of the cases.

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“…The radicular arteries derive from the lumbar arteries originating from branches of the aorta and supply blood to the spinal nerves and nerve roots. [10] The radicular artery enters the intervertebral foramen along the nerve root; the probability that the artery is in the upper part of the foramen is around 2-fold greater than the probability of it being in the lower part, and there is an increased risk of damaging the vessel during needle entry through the “safe triangle.” [11]…”

Section: Discussionmentioning

confidence: 99%

Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site

Kim¹,

Lee²,

Kim³

et al. 2019

Medicine

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Rationale: Transforaminal epidural steroid injection (TFESI) is a conservative method to treat back pain due to radiculopathy. However, epidural hematoma can occur after the procedure by various mechanisms, which can cause serious complications. Patient concerns: An 82-year-old man with spinal stenosis was treated with TFESI in the right intervertebral foramen at the L2-L3 level. The next morning, he experienced severe back pain and diffuse motor deficit. Diagnosis: Emergency magnetic resonance imaging revealed fluid collection in the posterior epidural space at the T11-L1 level with central-canal stenosis. Interventions: Emergency hematoma evacuation was performed to remove the epidural hematoma. Outcomes: After the surgery, the back pain disappeared. Lessons: Epidural hematoma may occur due to causes other than direct needle injury after TFESI. Therefore, careful observation of the patient is necessary after the procedure.

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The Lumbar Neural Foramen and Transforaminal Epidural Steroid Injections: An Anatomic Review With Key Safety Considerations in Planning the Percutaneous Approach

Abstract: Although no consensus currently exists about which approach is the safest, knowledge of the foraminal anatomy is a key consideration when choosing a needle approach for transforaminal epidural steroid injections.

Cited by 53 publications

References 50 publications

Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal

Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal

Transforaminal Insertion of a Thermocouple on the Posterior Vertebral Wall Combined with Hydrodissection during Lumbar Spinal Radiofrequency Ablation

Spinal epidural hematoma occurring at a distance from the transforaminal epidural injection site

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