Comparison of Lumbar Transforaminal Epidural Dexamethasone and Triamcinolone for Lumbar Radiculopathy

Epidural blockade is becoming one of the most useful and versatile procedures in modern anaesthesiology. What is unique is its application to clinical practice, as it can be placed virtually at any spinal level of vertebral column that allows considerable flexibility. Epidural steroid injections through lumbar transforaminal route to treat pain in lower back where radiculopathy is also associated with, are used widely. It has been reported that these procedures in lumber spine are effective clinically for improved physical function in patients as well as relief of pain of short- and long-term duration. We wanted to determine as to whether there is a difference in the efficacy between nonparticulate (e.g. dexamethasone phosphate) and particulate (e.g. triamcinolone acetate) steroids in Lumbar Epidural via transforaminal approach for acute radicular pain in lumber region and adverse effects of the drugs if any. METHODS66 patients, 33 in each group, with dexamethasone phosphate 8 mg or triamcinolone acetate 40 mg for lumbar transforaminal approach epidural steroid injection, were randomized. Observation was done through visual analog scale, short McGill pain questionnaire, revised Oswestry Disability Index before intervention and a month later. RESULTSA difference which was significant statistically in the visual analog score (2.85 ± 0.83 in group T, 5.76 ± 0.75 in group Dx), McGill Pain Questionnaire (3.73 ± 1.15 in group T, 6.55 ± 0.51 in group Dx) and Oswestry Disability Index (18.67 ± 7.13 in group T, 35.83 ± 5.10 in group Dx ) was found in both but was more in triamcinolone group. CONCLUSIONSEfficacy is more in particulate (triamcinolone) than non-particulate (dexamethasone) in epidural injection through lumbar transforaminal with no drug related complication, performed for radiculopathy in lumbar region.

Ultrasound-guided Transforaminal Epidural Injection in Pigs / 中国康复理论与实践

Objective:To observe the feasibility and accuracy of ultrasound-guided transforaminal epidural injection. Methods:Ultrasound-guided injection at L1-2, L2-3, L3-4, L4-5, L5-6 bilaterally was performed in L1-6 spine from two Bama miniature pigs. The position of needles was detected with X-ray and CT, and observed under anatomy. The distance from the puncturing points at skin to the posterior midline, the depths and angles of puncturing between were measured and compared bilaterally. Results:The successful rate was 95% (19/20), out of which, 80% (16/20) were put the needle tips at the lower part of the intervertebral foramen, ventral side, central region or paracentral region. There was no significant difference between sides in the distances, depths or angles in 19 successful injections. Conclusion:It is accurate to transforaminally puncture under ultrasound-guided.

Analysis of Influencing Factors to Depth of Epidural Space for Lumbar Transforaminal Epidural Block in Korean

BACKGROUND: Transforaminal epidural steroid injection is one of the effective treatments in managing radicular pain. There have been some prospective studies on the depth to the epidural space with the transforaminal approach. However, there have been no studies about the depth in Asians, especially Koreans. This study was carried out in order to evaluate the depth to the epidural space and the oblique angle and factors that influence the depth to the epidural space during lumbar transforaminal epidural injection. METHODS: A total of 248 patients undergoing fluoroscopically guided transforaminal epidural steroid injections were evaluated. At the L3-4, L4-5, L5-S1, and S1 levels, we measured the oblique angle and depth to the epidural space. RESULTS: Needle depth was positively associated with body mass index (correlation coefficient 0.52, P = 0.004). The median depths (in centimeters) to the epidural space were 6.13 cm, 6.42 cm, and 7.13 cm for 50-60 kg, 60-70 kg, and 70-80 kg groups, respectively, at L5-S1. Age and height were not significantly associated with the needle depth. CONCLUSIONS: There is a positive association between the BMI (and weight) and transforaminal epidural depth but not with age, sex, and height.

Analysis of Intravascular Flow Patterns following Cervical Transforaminal Epidural Injection

BACKGROUND: Transforaminal epidural injection (TEI) may be useful to treat unilateral pain that has a dermatomal distribution. In this approach, the needle tip can be placed closer to the dorsal root ganglion and ventral aspect of the nerve root. However many studies have reported that serious complications following TEI occurred more frequently when it was conducted at the cervical level. One of the presumptive mechanisms of the complication is intravascular injection. Therefore this study was conducted to identify the incidence of complications in response to intravascular injections at cervical segments. METHODS: This study included all patients, who visited our pain clinic and had radicular symptoms or herpes zoster associated pain. All procedures were conducted under fluoroscopic guidance with contrast enhancement by one of the authors. After the ideal needle position was confirmed by biplanar fluoroscopy, the blood aspiration through the needle hub was evaluated, and a 3 ml mixture of nonionic contrast (2 ml) with normal saline (1 ml) was injected at a rate of 0.3-0.5 ml/sec continuously under real time fluoroscopic visualization. We then classified the contrast spreading pattern as neural, simultaneous neural and vascular, or vascular. RESULTS: A total 71 cervical TEIs were performed. In 26 cases (36.6%), the contrast only spread to the nerve sheath. However, 45 cases (63.4%) showed an intravascular spreading pattern, 37 (52.1%) of which showed a neural and vascular pattern and 8 (11.3%) of which showed only a vascular pattern. CONCLUSIONS: Approximately two thirds of the cases of cervical TEI were found to lead to intravascular spreading, which is much higher than the incidence reported in previous studies.

An Analysis of Pattern of Transforaminal Epidurography / 대한통증학회지

BACKGROUND: A transforaminal epidural steroid injection has been used for the treatment of radicular arm or leg pain, which has the advantage of ventral epidural spreading compared to either an interlaminar or caudal approach. However, several factors are known to affect the epidural spread pattern of contrast dye; therefore, the injected medication can not be delivered to the target site. The objective of our study was to observe any differences in the contrast flow patterns according to several factors. METHODS: A total of 34 epidurographies in 29 patients, who underwent fluoroscopically guided transforaminal epidural steroid injections, were evaluated. After confirming the location of the needle tip within the anterior superior aspect of the neural foramen in the lateral view, and at the 6 o'clock position to the pedicle in the anteroposterior view, 2 ml of contrast dye was injected. The contrast flow patterns of ventral, ventral and dorsal, and dorsal epidural filling were analyzed, according to age, gender, magnetic resonance imaging finding and history of previous back surgery. RESULTS: Ventral contrast flow occurred in 30 out of the 34 epidurographies (88%). Both ventral and dorsal contrast flow patterns were observed 13 out of 16 (81%) patients in the older age group. Also, both ventral and dorsal contrast flow patterns were observed in 16 out of 18 (88%) patients with spinal stenosis. CONCLUSIONS: Transforaminal epidural steroid injections, performed under fluoroscopy, provide excellent nerve root filling and ventral epidural spreading. Patients with spinal stenosis or an old age have both ventral and dorsal epidural spreading patterns.

Effect of Transforaminal Epidural Injection in Patients with Lumbar Radicular Pain

OBJECTIVE: To determine the therapeutic effect of transforaminal epidural injections in patients with refractory lumbar radicular pain. METHOD: Thirty-five patients with lumbar radicular pain who did not receive any other interventional procedures were studied. Transforaminal epidurograms and epidural steroid injections via eighty-nine intervertebral foramens were performed under C-arm fluoroscopic visualization. After confirmation of proper needle placement, 20~40 mg of triamcinolone and 1 cc of 2% lidocaine hydrochloride were injected into each safe triangle of the intervertebral foramen. Patients were evaluated for visual analogue scale (VAS) and straight leg raising (SLR) test at pre-injection, 1 week post-injection and 3 months post-injection. Changes over time were assessed statistically using ANOVA. RESULTS: The averages of VAS reduced significantly (p<0.05) from 5.6+/-1.8 at pre-injection, to 3.5+/-1.7 at 1 week pos-tinjection, to 2.1+/-2.0 at 3 months post-injection, respectively. The averages of SLR augmented significantly (p<0.05) from 51.6degrees +/- 16.7degrees at pre-injection, to 66.6degrees +/-16.0degrees at 1 week post-injection, to 77.2degrees +/- 15.1degrees at 3 months post-injection, respectively. Twenty-six out of thirty-five patients (74.3%) had a successful long-term outcome, reporting at least an over 50% reduction between pre-injection and 3 months post-injection in VAS. CONCLUSION: Transforaminal epidural injection is an effective treatment for patients with lumbar radicular pain when evaluated after 1 week and 3 months post-injection.