Transforaminal Epidural Steroid Injection for Lumbosacral Radiculopathy: Preganglionic versus Conventional Approach

Abstract

ObjectiveThe present study was undertaken to evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) with using a preganglionic approach for treating lumbar radiculopathy when the nerve root compression was located at the level of the supra-adjacent intervertebral disc.Materials and MethodsThe medical records of the patients who received conventional TFESI at our department from June 2003 to May 2004 were retrospectively reviewed. TFESI was performed in a total of 13 cases at the level of the exiting nerve root, in which the nerve root compression was at the level of the supra-adjacent intervertebral disc (the conventional TFESI group). Since June 2004, we have performed TFESI with using a preganglionic approach at the level of the supra-adjacent intervertebral disc (for example, at the neural foramen of L4-5 for the L5 nerve root) if the nerve root compression was at the level of the supra-adjacent intervertebral disc. Using the inclusion criteria described above, 20 of these patients were also consecutively enrolled in our study (the preganglionic TFESI group). The treatment outcome was assessed using a 5-point patient satisfaction scale and by using a VAS (visual assessment scale). A successful outcome required a patient satisfaction scale score of 3 (very good) or 4 (excellent), and a reduction on the VAS score of > 50% two weeks after performing TFESI. Logistic regression analysis was also performed.ResultsOf the 13 patients in the conventional TFESI group, nine showed satisfactory improvement two weeks after TFESI (69.2%). However, in the preganglionic TFESI group, 18 of the 20 patients (90%) showed satisfactory improvement. The difference between the two approaches in terms of TFESI effectiveness was of borderline significance (p = 0.056; odds ratio: 10.483).ConclusionWe conclude that preganglionic TFESI has the better therapeutic effect on radiculopathy caused by nerve root compression at the level of the supra-adjacent disc than does conventional TFESI, and the diffence between the two treatments had borderline statistical significance.

Efficacy of Epidural Steroid Injection in Management of Lumbar Prolapsed Intervertebral Disc: A Comparison of Caudal, Transforaminal and Interlaminar Routes

“…Another study done by Hee Sun Jeong and Joon Woo Lee on 239 patients of lumbar disc prolapse was conducted consisting of 106 males and 133 females [13]. The average age of patient was 49.8 (13-82) years.…”

“…Macnab et al, (1971) described Selective Nerve Root Blocks (SNRBs) as a diagnostic test to evaluate patients with negative imaging studies and clinical finding of nerve root irritation [9]. Since then many studies have reported the efficacy of this technique through the transforaminal route [10][11][12][13][14][15]. Warr et al, (1972) reported good results in 63% of their series of 500 patients [16], in whom epidural medication of 40 ml of 0.75% lignocaine mixed with steroid was injected through L3-L4 interspace in the epidural space.…”

Transforaminal epidural steroid injection via a preganglionic approach for the treatment of lumbar radicular pain

“…The procedure was performed by the preganglionic approach described by Le et al (16,17). They described that for the preganglionic approach, the landmark for needle insertion was slightly lateral to the pars interarticularis on the oblique view, and at the neural foramen near the nerve root impingement site at the supra adjacent disk level on the posteroanterior view.…”

“…TFESIs were performed in the operation theatre equipped with a planar fluoroscope (Siemens TM , Munich, Germany) while the patients were prone. After sterile preparation, draping, and local anesthesia with one per cent lidocaine, a 9-cm long, 21- (16,17) described that for the preganglionic approach, the landmark for needle insertion was slightly lateral to the pars interarticularis on the oblique view, and at the neural foramen near the nerve root impingement site at the supra adjacent disk level on the posteroanterior and oblique view ( Figure 1A, B). Then 0.5 mL of bupivacaine HCl (Marcaine Spinal 0.5% Heavy TM ; AstraZeneca, Istanbul) was injected (~1 min), followed by 40 mg (1 mL) of methylprednisolone acetate suspension [Depomedrol TM Eczacibasi Ilac San., Luleburgaz, Kirklareli].…”

“…dISCuSSIon TFESI (by using a preganglionic technique) provides the injected material closer to the site of neural impingement and allow the delivery of medicine more directly to reduce inflammation and relieve pain (11,16). Injections of the cocktail containing steroid and local anesthetics provide inhibition of prostaglandin synthesis, stabilization of cellular membranes, and suppression in immune responses, increase in neuronal blood flow, and washing out inflammatory mediators (such as interleukin-1, tumor necrosis factor and phospholipase A2), in addition to block nociceptive C fiber conduction (20,26).…”