Clinical observation of selective nerve block combined with percutaneous posterior endoscopic cervical discectomy in the treatment of cervical spondylotic radiculopathy / 西安交通大学学报(医学版)

【Objective】 To observe the short-term clinical effect of selective nerve block combined with percutaneous posterior endoscopic cervical discectomy （PPECD） in the treatment of cervical spondylotic radiculopathy. 【Methods】 We reviewed 22 patients who received selective nerve block combined with percutaneous posterior endoscopic cervical discectomy （PPECD） for cervical spondylotic radiculopathy from June 2018 to January 2020. We recorded Japanese Orthopaedic Association （JOA） score for treatment evaluation， visual analogue scale （VAS）， the neck disability index score （NDI） preoperative 1 day， postoperative 1 day， 1 month， 3 months， 6 months and 1 year. All data were imported into SPSS26.0 software for analysis and processing. Quantitative data are expressed as mean ± standard deviation. The scores of neck VAS， arm VAS， JOA and NDI were compared at different time points by repeated measurement analysis of variance. Paired t-test was used to compare each time point after operation and the first day before operation. P<0.05 was considered statistically significant， and the modified MacNab standard was used to evaluate the clinical effect at the last follow-up. 【Results】 All operations were successfully completed under ultrasound-guided selective nerve block combined with endoscopic operation. The average operation time was 125.6 minutes. The intraoperative blood loss was 2-100 mL and the average blood loss was 19.1 mL. All patients were followed up for 15-33 months， with an average follow-up of 24.1 months. No patients had spinal cord， nerve root and vascular injury， dural tear or other complications. Compared with the preoperative VAS score， the VAS score of neck and upper arm decreased significantly （P<0.05）， while the JOA score increased significantly （P<0.05）， and the preoperative NDI score decreased significantly （P<0.05）. At the last follow-up， the modified Macnab criteria showed there were 15 excellent cases， 5 good cases， 2 medium cases and 0 poor case. The excellence rate was 91%. Postoperative magnetic resonance imaging and 3D computed tomography reconstruction of the cervical spine showed that the disc had been fully removed and the nerve root compression at the surgical segment was relieved. 【Conclusion】 Ultrasound-guided selective nerve block combined with percutaneous posterior endoscopic cervical discectomy is a safe and effective minimally invasive surgical method for the treatment of cervical spondylotic radiculopathy with reliable short-term efficacy.

Imaging evaluation of short-segment fixation and fusion for degenerative lumbar scoliosis assisted by highly selective nerve root block / 中国组织工程研究

BACKGROUND: Short-or long-segment fixation is still controversial in the treatment of adult degenerative lumbar scoliosis. OBJECTIVE: To investigate the effectiveness and feasibility of accurate treatment of short-segment fixation in adult degenerative lumbar scoliosis patients assisted by highly selective nerve root block. METHODS: Thirty-five patients with adult degenerative lumbar scoliosis treated in Chinese PLA General Hospital and People’s Hospital of Peking University from May 2014 to September 2017 were analyzed retrospectively, including 14 males and 21 females aged (64.2±8.1) years. The fixation segments were determined by a highly selective nerve root block. All patients were subjected to transforaminal lumbar interbody fusion. During the follow-up, visual analogue scale score and Oswestry disability index were evaluated. Parameters including lumbar curvature Cobb angle, lumbar lordosis angle, sacral slope, and pelvic tilt and interbody fusion condition were obtained by imaging; and complications were recorded. This study was approved by the Ethics Committee of Chinese PLA General Hospital and People’s Hospital of Peking University. RESULTS AND CONCLUSION: (1) Of the 35 patients, 27 underwent single-segment minimally invasive transforaminal lumbar fusion, 5 underwent double-segment minimally invasive transforaminal lumbar fusion, and 3 underwent three-segment minimally invasive transforaminal lumbar fusion. (2) The follow-up time of 35 patients was (25.6±1.5) months. All patients achieved the grade I fusion. Within 3 months, there were 3 cases of dural tear and cerebrospinal fluid leakage, 1 case of lower-extremity muscular venous thrombosis, 1 case of pneumonia and 1 case of wound fat liquefaction. Three months later, there was 1 case of adjacent segment degeneration; no nerve injury or nonunion, no screw or titanium rod breakage. (3) Visual analogue scale score, Oswestry disability index, Cobb angle, lumbar lordosis angle, sacral slope, and pelvic tilt at the last follow-up were significantly improved in 35 patients compared with those before surgery (P < 0.01). (4) Short-segment precision treatment of adult degenerative lumbar scoliosis with highly selective nerve root block can achieve good clinical effect.

When is the Optimal Time Point for Predicting the 1-Year Follow-up Outcome of Selective Nerve Root Block for Cervical Radiculopathy?

STUDY DESIGN: Retrospective study. OBJECTIVES: In the current study, we aimed to (1) evaluate the early and late therapeutic effects of selective nerve root block (SNRB) for cervical radiculopathy, and (2) to determine the optimal time point for predicting the long-term effectiveness of cervical SNRB. SUMMARY OF LITERATURE REVIEW: Although SNRB is an important option for cervical radiculopathy, various studies of cervical SNRB have failed to specify its efficacy, especially long-term effectiveness. MATERIALS AND METHODS: We retrospectively enrolled 35 patients with cervical radiculopathy who were regularly followed-up for at least 1 year after SNRB. Clinical outcomes were evaluated using a visual analogue scale (VAS) for pain intensity and the modified Kim's method for patient satisfaction at regular follow-up intervals. In the correlation analysis, stepwise multiple linear regression was used to identify selected and unselected factors. RESULTS: The average VAS score decreased over time (p<0.05); the values just before the injection and at 1 week, 3 weeks, and 1 year of follow-up were 6.11, 3.29, 2.89, and 1.37, respectively. In the stepwise multiple regression analysis, the 1-week VAS score was related to the initial VAS score, the 3-week VAS score was related to the 1-week VAS score, and the last VAS score was related to the 3-week VAS score and symptom duration before the injection. The degree of satisfaction at the 1-year follow-up point was significantly associated with the 3-week VAS score (p=0.011). CONCLUSIONS: The current study showed that pain intensity at the 3-week time point after cervical SNRB might be the optimal time point for predicting long-term effectiveness.

Application of ultrasound-guided selective cervical nerve root block for patients undergoing arthroscopic surgery in perioperative period / 临床麻醉学杂志

Objective To compare effectiveness,performance,and complications between ultrasound-guided selective cervical nerve root block and interscalene brachial plexus block for patients undergoing arthroscopic surgery in perioperative period.Methods Seventy patients scheduled for arthroscopic surgery,25 males and 45 females,aged 18-75 years,were randomly divided into two groups.They were given either selective cervical nerve root block (group S,n =35) or interscalene brachial plexus block (group ISB,n=35).In group S,C5 and C6 nerve roots were given 0.5％ ropivacaine 5 ml respectively;In group ISB,patients were given 0.5％ ropivacaine 10 ml under ultrasound guidance.The primary outcome:VAS score and forearm modified Bromage scale (MBS) score were recorded at 4,12 and 24 hours after surgery;Secondary outcomes:cumulative tramadol consumption,the patients' satisfaction rate and adverse effects were recorded.Results The VAS scores in group S was significantly lower than that in group ISB at 12 hours after surgery (1.7±0.8 vs 3.6±0.7,P＜0.05).The forearm MBS scores in group S was significantly higher than that in group ISB 4 hours after surgery (P＜0.01).Compared with group ISB,the amount of tramadol consumption was lower at 24 hours after surgery [(37.5±35.9) mg vs (112.5±43.5) mg,P＜0.05)].The satisfaction rate of group S was higher than group ISB (88％ vs 56％,P＜0.05).There was no significant difference in side effects between the two groups.Conclusion In arthroscopic surgery,the selective cervical nerve root block is superior to the brachial plexus block.

The Usefulness of Selective Nerve Root Block for Failed Back Surgery Syndrome / 대한정형외과학회잡지

PURPOSE: To retrospectively evaluate the improvement of symptoms and diagnosis using selective nerve root block (SNRB) for radiating pain after spine surgery. MATERIALS AND METHODS: From October 2012 to October 2013, 112 patients with failed back surgery syndrome (41 male and 71 female, with the mean age of 62.4 years and range of 35 to 78 years), who were admitted and underwent SNRB, were included. All patients were followed-up for more than 12 months. Three groups were classified: Group 1 included patients with no improvement or aggravation of symptoms, group 2 included those with improvement of radiating pain, and group 3 included those with recurrence of radiating. RESULTS: Among the 112 patients, there were 15 patients in group 1, 59 patients in group 2, and 38 patients in group 3. Laminectomy was the highest surgical procedure, inducing failed back surgery syndrome. In group 2, the occurrence of failed back surgery syndrome was higher in case that radiating pain was complained more than 1 year before the first surgery. There is statistically significant symptom improvement in accordance with the visual analogue scale and Korean version of Oswestry disability index on every group after SNRB (p<0.05). CONCLUSION: It is considered that SNRB is expected to improve the symptoms and to find the cause of symptoms as a diagnostic value even after spine surgery.

Analysis of SNRB in patients with lumbar radiculopathy resistant to conservative treatment.

Background: The transforaminal application performed with SNRB (Selective nerve root blocks) should be more accurate. Moreover, the amount of corticosteroid and local anesthetic can be reduced compared to the amount of these agents administered with the epidural steroid. Methods: Prospective study of 72 patients with low back pain done in Sri Ramachandra medical centre, Chennai during April 2012 to April 2014. 46 patients were diagnosed to have inter vertebral disc and 26 patients with Lumbar canal stenosis. The patients were evaluated using VAS score and Oswestry disability index. The indication and determination of the therapeutic SNRB level was established by the spine surgeon after all the diagnostic test results had been obtained and after a detailed discussion with the patient. After confirming the correct placement of spinal needle with a short bevel with the help of contrast, a solution of 1ml of 0.5% sensorcaine with 1 ml of triamcinolone acetonide (Inj. kenocort) is injected. Results: Only 2 patients out of 72 had persistent pain and underwent surgery. 60 of our patients were comfortable and were able to proceed with their normal life/day to day activities following the administration of one block. Conclusion: Selective nerve root block is effective and less invasive intervention, and serves as an adjunct to non-operative treatment. The blocks give the best result in disc herniation cases, followed by favorable results in foraminal stenosis.

The Usefulness of Selective Spinal Nerve Root Block in Neuropathic Pain Patients with Radiculopathy / 대한정형외과학회잡지

PURPOSE: This study was conducted in order to evaluate effect and efficiency of selective spinal nerve root block for neuropathic pain patients with lower leg radiating pain. MATERIALS AND METHODS: A total of 113 patients were evaluated and follow-up periods were a minimum of 12 months. They were divided into two groups: group A included 41 patients with neuropathic pain and group B included 72 patients with simple lower leg radiating pain. RESULTS: Fourteen (34.1%) patients in group A and 45 (62.5%) patients in group B had favorable results for selective spinal nerve block (p<0.05). Visual analog scale (VAS) was improved from 7.57 to 5.23 at 12 months in group A and from 7.11 to 3.49 at 12 months in group B. CONCLUSION: The initial treatment period for group A was significantly later than in group B. For patients with neuropathic pain and radiculopathy, early assessment was recommended and early selective spinal nerve block could be a good treatment option for neuropathic pain patients.

Management of Patients with L2 Spinal Nerve Root Block Who Are Suffering from Low Back and Referred Pain

STUDY DESIGN: Prospective clinical study. OBJECTIVES: The aim of the study was to verify the effectiveness of L2 spinal nerve root block for patients who are suffering from low back pain and referred pain with compound causes. SUMMARY OF LITERATURE REVIEW: Most of low back pain and referred pain arises from discs, facet joints and sacroiliac joints. All structures above have the pain perception pathway through sympathetic nerves with a connection to L2 spinal nerves. MATERIALS AND METHODS: We selected patients with low back pain and referred pain for more than 2 weeks. Each 50 patients were randomly allocated to an experimental and a control group.The experimental group underwent a L2 spinal nerve root block with 2cc of 0.25% bupibacaine at the symptom dominant side. The control group underwent a skin infiltration with 2cc of 2% lidocaine only. The pain was assessed with a visual analogue scale (VAS) consisting of 100 points at 5minutes, day 1, day 3, day 5, day 7 and day 30 postprocedure. RESULTS: Both groups showed a significant improvement after the procedures(p=0.000). However, a greater improvement was shown in the experimental group(p=0.000). In the individual analysis, the experimental group had improved as time elapsed and the significancewas maintained until 30 days. However, in control group, the significance was lost at day 30. CONCLUSION: L2 spinal nerve root block is recognized to reduce the low back and referred pains which arise from compound causes in a degenerative spinal disease.

Clinical Results and Efficacy of Selective Nerve Root Blocks with Vertebroplasty in Treatment of Patients with Osteoporotic Compression Fracture Accompanied by Spinal Stenosis / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the efficacy of selective nerve root blocks with vertebroplasty in treatment of patients with osteoporotic compression fracture accompanied spinal stenosis showing neurogenic claudication. MATERIALS AND METHODS: Of 80 patients admitted to our orthopedic department for osteoporotic vertebral compression fracture accompanied by neurogenic claudication due to spinal stenosis between May 2010 and September 2011, 40 patients who underwent only vertebroplasty and 40 patients who also underwent an additional selective nerve block were studied with a minimum follow-up period of one year. The two groups were compared for their age, sex, grade of spinal stenosis, bone mineral density (BMD), lordotic angle, pelvic tilt, sacral slope, pelvic incidence, restoration rate of vertebral height, preexisting fracture, intradiscal cement leakage, and for new adjacent vertebral fractures during a follow-up period of at least one year. Statistical analysis was performed using SPSS version 17.0 and statistical significance was determined using the Student t-test and chi-square test with p or =0.05) in age sex, grade of spinal stenosis, BMD, lordotic angle, pelvic tilt, pelvic incidence, restoration of vertebral height, preexisting fracture, and intradiscal cement leakage was observed between the vertebroplasty only group and the additional selective root block group. However, the incidence of new adjacent vertebral fractures between the groups was 13 of 40 patients in the vertebroplasty only group and four of 40 patients in the selective nerve block addition group; a statistically significant reduction was observed in the nerve block group (p<0.05). CONCLUSION: In treatment of patients with osteoporotic compression fracture with neurogenic claudication due to spinal stenosis, addition of selective nerve block to vertebroplasty can lessen pain and the resulting postural change, thereby mitigating dynamic sagittal instability, which in turn results in reduced incidence of new adjacent vertebral fractures. As such, selective nerve block should be considered as a safe, simple, and effective tool for use in prevention of new adjacent vertebral fractures in patients with osteoporotic fracture who are suffering from neurogenic claudication.

The Short Term Results of Selective Nerve Root Block in Spinal Stenosis by Contrast Pattern

STUDY DESIGN: Retrospective study. OBJECTIVES: To observe the short term effect of selective nerve root block (sNRB) depending on the contrast pattern and spinal canal size. SUMMARY OF LITERATURE REVIEW: A number of studies have demonstrated that sNRB is quite effective not only for patients with herniated intervertebral discs but also for those with spinal stenosis. MATERIALS AND METHODS: The Visual Analog Scale(VAS) score was collected before and after the procedure from 217 subjects with lumbar spinal stenosis and underwent sNRB. Two types were classified after observing the contrast's spreading pattern, Type I contrast reaching the spinal canal and Type II not reaching the spinal canal. Efficacy of the treatment for each type was also compared. In addition, the spinal canal size was classified into three categories. Treatment efficacy depending on the contrast pattern was also compared in each category. RESULTS: When divided into two types based on the contrast pattern, type I showed a more significant reduction in VAS score according to T-test although both types showed a decrease in VAS score after the procedure. In regards to spinal canal dimension, both types showed decreased VAS scores after the procedure in patients with spinal canal size larger than 172.2mm2; however, there were no changes in VAS score before and after the procedure for those with spinal canal size smaller than 73mm2. CONCLUSIONS: There was a short term effect of selective nerve root block (sNRB) in patients with spinal stenosis regardless of their contrast pattern, type I group showing a stronger correlation. In regards to spinal canal dimension, patients with larger spinal canal sizes not only showed a significant decrease in VAS score after selective nerve root block (sNRB) but also showed differences depending on the contrast pattern. On the contrary, there was no significant difference in VAS score before and after selective nerve root block (sNRB) in patients with small spinal canal sizes, and there was also no difference in the outcome depending on the contrast pattern in patients with small spinal canal sizes. Therefore, when performing selective root nerve block (sNRB), the operator should remember to manipulate the angle and position of the spinal needle when injecting the appropriate drug after confirming that the contrast material reached the spinal canal. The operator should also consider surgical management when performing selective nerve root block (sNRB) in patients with severe central spinal stenosis.

Effectiveness of Selective Nerve Root Block for the Treatment of Radiculopathy in Degenerative Lumbar Scoliosis

STUDY DESIGN: Level III, Retrospective studies. OBJECTIVES: This study was conducted to evaluate the effects and usefulness of the selective nerve root block in advance for the Degenerative Lumbar Scoliosis patients, with radiating pain, who were scheduled for an operation. SUMMARY OF LITERATURE REVIEW: Selective nerve root block was introduced in 1971, by Macnab and it was used to make improvements for radiating pain, as a treatment of multiple lesions or a tool to help making a surgical decision, and to predict the result. After an introduction by Cooper, selective root block on degenerative sclerosis, with lower leg radiating pain, showed fine results on a short term follow-up and moderate to good results on long term follow-up. MATERIALS AND METHODS: Between January 2005 to December 2009, 47 cases were selected from the patients, who underwent selective nerve root block, before the operation. The mean follow-up period was 38.4 months and the mean age was 67.1 years. The patients were divided into the operation group and the only selective nerve root block group. The treatment results in the SNRB group and the operation group were analyzed using Kim's criteria and the Visual Analog Scale score. The groups were radiologically evaluated for the neural compression rate. RESULTS: Among the 47 cases that were scheduled for an operation, 30 cases did not proceed to the operation. The average VAS score for the selective root block group and the operation group were 7.56 and 8.12, at the preoperative state and the preinjection state, respectively. After the selective nerve root block and surgical treatment, the scores were 3.71 and 2.64 at 1year follow up, respectively. There was no correlation with statistical significance between the initial VAS score and the degree of stenosis noted in the MRI (P>0.05). There was no statistical significant correlation between the initial relief from selective nerve root injections and the degree of stenosis noted in the MRI (P>0.05). However, there was a correlation with statistical significance between the operation rate and the degree of stenosis noted in the MRI (P<0.05). CONCLUSION: Selective nerve root block is considered to be an effective treatment for the Degenerative Lumbar Scoliosis patients with radiating pain, who are scheduled for an operation.

The Value of Selective Nerve Root Block to Predict Surgical Outcome for Spinal Surgery

OBJECTIVE: The aim of this study was to evaluate the prognostic value of the selective nerve root block prior to the surgery. METHODS: Between January 2007 and December 2009, 52 cases of selective nerve root block prior to the spine surgery were performed. Three cervical lesions and 49 lumbar spinal lesions were selected. All selected patients had multilevel spine lesions or poorly defined radiologic findings with significant symptoms of neural foramen stenosis. RESULTS: In total of the 52 patients, 41 had positive and 11 had negative results with the nerve root block. Out of the 41 patients with positive results, 40 patients had good surgical outcome. From the 11 patients with negative results, 6 patients had good surgical outcome. All surgeries were performed at the positive level at the selective nerve root block and the most suspected lesion. CONCLUSION: Selective nerve root block can be used to evaluate the location generating the most serious radiating pain. Results of selective nerve root block corresponded with the results of the surgical outcome in the most cases. We can predict the outcome of the surgery, especially in case of multilevel spine problems or poorly defined radiologic findings, by performing preoperative selective nerve root block.

An Analysis of Location of Needle Entry Point and Palpated PSIS in S1 Nerve Root Block

BACKGROUND: The first sacral nerve root block (S1NRB) is a common procedure in pain clinic for patients complaining of low back pain with radiating pain. It can be performed in the office based setting without C-arm. The previously suggested method of locating the needle entry point begins with identifying the posterior superior iliac spine (PSIS). Then a line is drawn between two points, one of which is 1.5 cm medial to the PSIS, and the other of which is 1.5 cm lateral and cephalad to the ipsilateral cornu. After that, one point on the line, which is 1.5 cm cephalad to the level of the PSIS, is considered as the needle entry point. The purpose of this study was to analyze the location of needle entry point and palpated PSIS in S1NRB. METHODS: Fifty patients undergoing C-arm guided S1NRB in the prone position were examined. The surface anatomical relationships between the palpated PSIS and the needle entry point were assessed. RESULTS: The analysis revealed that the transverse and vertical distance between the needle entry point and PSIS were 28.7 +/- 8.8 mm medially and 3.5 +/- 14.0 mm caudally, respectively. The transverse distance was 27.8 +/- 8.3 mm medially for male and 29.5 +/- 9.3 mm medially for female. The vertical distance was 1.0 +/- 14.1 mm cranially for male and 8.1 +/- 12.7 mm caudally for female. CONCLUSIONS: The needle entry point in S1NRB is located on the same line or in the caudal direction from the PSIS in a considerable number of cases. Therefore previous recommended methods cannot be applied to many cases.

Acute Spinal Cord Injury after Cervical Nerve Root Block / 대한정형외과학회잡지

Selective cervical nerve root block is a widely utilized nonsurgical strategy for the management of cervical radicular and axial pain. The technique has been shown to be efficacious in relieving the patient's symptoms. Although effective, there are a range of possible complications associated with this procedure. In particular, acute spinal cord injury after cervical nerve root block is very rare, but it lead to serious functional impairment. The literature on acute spinal cord injury is very small and there have been no reports from Korea. We experienced a case of a patient with an acute injury of the cervical spinal cord after cervical nerve root block who was followed 28 months.

Transforaminal Selective Nerve Root Blocks for Treating Single Lumbosacral Radiculopathy: The Short-term Outcome and Efficiency / 대한정형외과학회잡지

PURPOSE: We wanted to determine the clinic usefulness of selective nerve root block for treating lumbosacral radiculopathy that's due to a herniated nucleus pulposus (HNP) or foraminal stenosis (FS) by analyzing the short-term results after the selective nerve root block (SNRB) procedure. MATERIALS AND METHODS: Sixty-five patients were investigated in our research. Sixty-five patients were divided into two groups: thirty-seven patients of group one were the HNP patients and twenty-eight patients of group two were the FS patients. The effect of SNRB treatment was assessed by the degree of radiating pain in lower legs with using the visual analogue scale (VAS) and patients' subjective satisfaction. The average overall follow-up period was eleven months: that of the first group was 13.5 months and that of the group was 7.6 months. RESULTS: For the 65 patients, the average VAS was 7.8 before a SNRB procedure and this decreased to 2.9 and 3.4 after one to three SNRB procedures, respectively. For group one, the VAS was 7.4 before the procedure and it decreased to 3.3 at one month and 3.7 at three months after the procedure. For group two, the VAS was 8.3 before the SNRB procedure and this favorably changed to 2.3 at one month and 3.0 at three months after the procedure. An operation was carried out due to no response for 8 patients (12%) and due to aggravation for 4 patients (6%) after the SNRB procedures. Three patients (8%) of group one and two patients (11%) of group two obtained pain relief at one month and aggravation at three months, respectively. On comparing the two groups, a better treatment effect was observed for the FS group after one month (p=0.002) and three months (p=0.01). Complications related to the SNRB procedure haaves not been observed in both groups. CONCLUSION: The SNRB procedure is a very effective and safe procedure, after the appearance of symptoms, as a non-operative treatment for single lumbosacral radiculopathy due to a herniated nucleus pulposus or foraminal stenosis. This treatment appears to be more effective for the FS group than for the HNP group and it should be considered before carrying out an operative treatment.

Effectiveness of Selective Nerve Root Block on the Need for Surgical Treatment of Lumbar Spine: A Minimum 5 Years Follow up / 대한정형외과학회잡지

PURPOSE: To evaluate the effectiveness of a selective nerve root block (SNRB) in patients with sciatica before surgery through a more than 5 year follow up. MATERIALS AND METHODS: Between January 2000 and December 2000, patients with sciatica, who were recommended to undergo surgery to diagnose and treat sciatica by other clinics or at our hospital, were selected to undergo SNRB before surgery. Among them, 69 patients were followed up for 5 years. The analysis was based on the patients' medical records and telephone interviews, and the treatment results in the SNRB group and operation group were analyzed using Kim's criteria and the Visual Analog Scale score. RESULTS: Among the 69 patients, there was no improvement in symptoms in 37 patients after SNRB. Therefore, they underwent surgery. The symptoms of the remaining 32 patients were improved by SNRB. Overall, younger patients and those with a longer symptom duration required surgery. CONCLUSION: SNRB was performed on patients with sciatica who were scheduled to undergo surgery. Some patients showed improvement in their symptoms in the long term. Therefore, SNRB should be considered as a treatment option prior to surgery.

Bloqueo radicular selectivo en hernia del núcleo pulposo lumbar primaria lateral / Selective nerve root blocks in the treatment of primary lateral lumbar disc herniation

Purpose: Evaluate the use of selective nerve root blocks in the treatment of primary lateral lumbar disc herniation (foraminal and/or extraforaminal). Method: Retrospective case series. We identified all the patients who underwent a selective nerve root block in our hospital between January 2001 and June 2006. We selected patients with primary lateral and far lateral lumbar disc herniation. We excluded those with previous spine surgery or with other type of spine pathologies. Relevant data was gathered and statistically analyzed (using Fisher’s exact test) to determine possible associations between the evaluated variables and treatment failure (i.e. the need for spine surgery). Results: We identified 24 patients (8 women and 16 men), mean age 54 years (33-75), with a median follow up of 40 months (14-75). The most frequent level of the herniation was L3-L4 (41,6 percent),followed by L4-L5 (37,5 percent). Sixteen patients (66,6 percent) had foraminal herniations, 2 patients had extraforaminal herniations, while the remaining 6 patients had both foraminal and extraforaminal herniations. Five patients (20,8 percent) presented treatment failure, requiring spine surgery. No statistically significant differences were detected among age, sex, paresis and previous epidural infiltrations with treatment failure. A clear tendency of association between treatment failure and patients under a workers’ compensation program was observed. We identified a statistically relevant higher treatment failure rate in heavy workers and patients with L3-L4 disc herniations. Conclusion: In this series, selective nerve root blocks had an 79,2 percent success rate, considering prevention of spine surgery as the main endpoint, with an adequate follow up. Heavy workers and L3-L4 disc herniations had a higher treatment failure rate.

Objetivo: Evaluar resultados del tratamiento con bloqueo radicular selectivo (BRS) en pacientes con hernia del núcleo pulposo (HNP) lumbar primaria lateral (foraminal y extraforaminal). Material y Método: Estudio retrospectivo de una serie de casos. Se realizó búsqueda de todos los pacientes tratados con bloqueos radiculares selectivos en nuestro hospital, entre enero de 2001 y junio de 2006. Se seleccionaron pacientes con diagnóstico de HNP lumbar primaria lateral. Se excluyeron aquellos pacientes con cirugía de columna previa o con patología de otro tipo. Se consignaron los datos relevantes y se realizó un análisis estadístico contest exacto de Fisher para evaluar la relación entre las variables categóricas estudiadas y el fracaso del tratamiento, definido como la necesidad de cirugía. Resultados: Se identificaron 24 pacientes (8 mujeres y 16 hombres), edad promedio 54 años (33-75). Mediana de seguimiento de 40 meses (14-75). La localización más frecuente de la HNP fue el nivel L3-L4 (41,6 por ciento), seguido por L4-L5 (37,5 por ciento). El 66,6 por ciento de los casos (16 pacientes) correspondían a una HNP foraminal, 2 pacientes tenían una HNP extraforaminal y en 6 pacientes la hernia se ubicaba tanto en la forámina como en el espacio extraforaminal. Cinco pacientes (20,8 por ciento) presentaron falla al tratamiento, requiriendo cirugía de resección herniaria. No se evidenciaron diferencias estadísticamente significativas entre la edad, sexo, paresia asociada e infiltraciones previas con la necesidad de cirugía. Existió una clara tendencia de asociación entre la necesidad de cirugía y aquellos pacientes sometidos a compensación. Se identificó un mayor fracaso de tratamiento, con diferencia estadísticamente significativa, en aquellos pacientes que realizaban trabajo pesado y en los que presentaban una HNP en nivel L3-L4. Conclusiones: En esta serie, el BRS tiene un 79,2 por ciento de éxito en el manejo de los pacientes con HNP lumbar primaria lateral...

Effectiveness of Selective Nerve Root Block on the Need for Surgical Treatment of Lumbar Disc Herniation / 대한정형외과학회잡지

PURPOSE: The purpose of the study is to evaluate the effectiveness of selective nerve root block (SNRB) in advance to the patient who is going to undergo the operation for lumbar herniated intervertebral disc (HIVD). MATERIALS AND METHODS: 103 cases were selected from among SNRB conducted to the patients who had been diagnosed by this hospital to have lumbar HIVD from December 2004 to November 2005 and assigned for operations. The follow-up period was 10 months in average (2.5-30 months) and the average age was 35.5 years (19-72 years). Patients had been monitored by means of clinical records, interviews and telephone and features of symptoms and stage of nerve root compression were compared between the group of operated patients and that of the non-operated. RESULTS: As for stages of nerve root compression, 15 cases could be classified to belong to the 1st stage, 4 cases to the 2nd stage and 1 case to the 3rd stage. Among 42 cases for which operations were conducted because there was no improvement after SNRB. Divided by stages of nerve root compression, 13 cases belonged to the 1st stage, followed by 10 cases to the 2nd stage and 4 cases to the 3rd stage. No statistically significant difference turned out to exist the clinical results between 42 cases which underwent operations and 61 cases which experienced improvement after nerve root block. No significant difference, either, was confirmed from the statistical outcomes between SNRB group and operations. CONCLUSION: The preserving treatment using SNRB for the patients with lumbar HIVD seems to have positive clinical effects. Features of radiating pains or stages of nerve root compression, however, can't be regarded to be factors foretelling the treatment effects of SNRB.

Selective Dual Nerve Root Block Through Extreme Lateral Transforaminal Approach

BACKGROUND: Selective nerve root block(SNRB) is often helpful for radiculopathy in geriatric patients when surgery is contraindicated and/or patients are poor candidate for surgery. However, multiple injections are often necessary with conventional SNRB for each pathologic level of polyradiculopathy. On the other hand, caudal or interlaminar epidural block cannot reach the pathologic area directly. We reviewed our experience with SNRB for both exiting and traversing nerve roots simultaneously by injecting directly to the ventral epidural pathologic area through extreme lateral transforaminal approach. METHODS: From March 2003 to June 2005, we performed extreme lateral transforaminal epidural injection with mixture of corticosteroid and local anesthetic in 25 patients. Both exiting and traversing nerve roots and ventral epidural area were identified with radio-opaque contrast media under C-arm fluoroscope. The outcome of treatment was measured using visual analog scale(VAS) score and Oswestry disability index(ODI) score. RESULTS: The mean age of 25 patients was 53.4 years and 17 of them were women. All of them complained low back pain and polyradiculopathy. After selective dual nerve root block, the average VAS score dropped from 8.5 to 4.3 for leg pain and 7.8 to 5 for low back pain. The ODI score dropped from 38 to 22. Symptom relief was maintained during 8-12 weeks. There was no complication in this procedure. CONCLUSION: With extreme lateral, transforaminal approach, we can block simultaneously both exiting and traversing nerve roots with single injection of corticosteroid and local anesthetic agent. Sinuvertebral nerve at the pathologic ventral epidural area can also be blocked. In patients with multi-level nerve abnormalities or complex postoperative back pain, this approach was effective therapeutic procedure that can block dual pathologic lesions directly with single injection

The Usefulness of Selective Nerve Root Block as a Predictor of Prognosis of Lumbar Disc Herniation / 대한척추외과학회지

STUDY DESIGN: A prospective study. OBJECTIVES: To investigate the usefulness of selective nerve root block (SNRB) as a prognosis predictor of a lumbar disc herniation. SUMMARY OF LITERATURE REVIEW: The biochemical factors of radiculopathy, as opposed to the biomechanical factors, are more reversible and responsive to a corticosteroid injection. MATERIALS AND METHODS: Fifty patients underwent SNRB for the radiculopathy caused by a herniated lumbar disc and were followed for at least 1 year. The straight leg raising (SLR) angle, visual analog scale (VAS) and the patients' subjective satisfaction, using the Weber criteria, were initially investigated, and again at 1 week and 1 month after the procedure, and finally at the final follow-up. The patients were divided into two groups according to the final satisfaction. Group 1 (satisfactory prognosis, N=32) had Excellent/Good results at the final follow-up, whereas Group 2(unsatisfactory prognosis, N=18) had Fair/Poor final results, or underwent surgical treatment. The improvements in the SLR and VAS at 1 week and 1 month were compared between two groups. The subjective satisfaction each time was compared to the final outcome; the relative risks were also calculated. RESULTS: The improvements in the SLR and VAS for Group 1 were significantly better than those for Group 2 at both 1 week and 1 month (p<0.05). Those patients with Excellent/Good results at 1 week and 1 month manifested satisfactory final outcomes (p<0.05). The risks of the patients with Fair/Poor results at 1 week and 1 month manifesting unsatisfactory final outcomes were 6.8 and 15.2 times higher than those with Excellent/Good results. CONCLUSION: Selective nerve root block could be a useful method, not only to relieve acute leg pain, but also to predict the longterm prognosis of a herniated lumbar disc. Early surgical treatment could be considered for the patients not manifesting significant improvement until 1 month after SNRB.