Hipo persistente: una rara complicación de una inyección epidural transforaminal de corticoides / Persistent hiccup: a rare complication of a transforaminal epidural corticoid injection / Soluços persistentes: uma complicação rara da injeção peridural transforaminal de corticosteroide

Se describe el caso de un paciente que instaló un hipo persistente luego de recibir una inyección epidural transforaminal lumbar de corticoides. Se destaca que es una complicación raramente reportada y por ende poco conocida por quienes practican intervencionismo en dolor. Se discuten los posibles mecanismos por los que puede presentarse, se reseña la evolución observada, y se describe el tratamiento instituido. Se señala el impacto que el hipo puede tener sobre la calidad de vida.

The case of a patient who installed a persistent hiccup after receiving a lumbar transforaminal epidural injection of corticosteroids is described. It is highlighted that it is a rarely reported complication and little known by those who practice interventional pain medicine. Possible mechanisms by which it may occur are discussed, the evolution observed and the treatment instituted are reviewed. The impact that hiccups can have on quality of life is pointed out.

Descrevemos o caso de um paciente que desenvolveu soluços persistentes após receber uma injeção peridural transforaminal lombar de corticosteróides. Ressalta-se que é uma complicação pouco relatada e, portanto, pouco conhecida por quem pratica o intervencionismo na dor. Discutem-se os possíveis mecanismos pelos quais pode ocorrer, revisa-se a evolução observada e descreve-se o tratamento instituído. O impacto que os soluços podem ter na qualidade de vida é apontado.

Influence of Epidural Steroid Injection on Adrenal Function

BACKGROUND: Spinal diseases are self-limited or non-progressive in many cases. Epidural steroid injection (ESI) is a common nonsurgical treatment option for spinal pain. Despite concerns about complications of repeated steroid injection, few studies reported on the adrenal function of spine disease patients undergoing surgery after ESI. We investigated the influence of preoperative multiple ESIs on adrenal function in spine surgery patients. METHODS: This was a retrospective study with prospective data collection. Those who underwent elective spinal operations and had a history of multiple ESIs from January to June 2017 were selected as a study group. Those who underwent knee arthroplasty and did not have a history of ESI and any kind of steroid injection in other areas during 6 months before surgery were selected as a control group. Demographic data were compared to assess homogeneity between groups. We assessed the preoperative serum cortisol level (SCL) to compare the basal adrenal function between groups. Also, we assessed the elevation of SCL postoperatively to evaluate the adrenal response to the surgical stress in each group. For subgroup analysis, we divided all patients into normal (7–28 µg/dL) and subnormal groups according to SCL and analyzed risk factors of adrenal suppression with multivariate logistic regression test. RESULTS: There were 53 patients in the study group and 130 in the control group. Age and sex were homogeneous between groups. There was significant intergroup difference in preoperative SCL (10.4 ± 4.8 µg/dL in the study group vs. 12.0 ± 4.2 µg/dL in the control group; p = 0.026).The postoperative day one SCL was 11.6 ± 5.0 µg/dL in the study group without significant increase from the preoperative level (p = 0.117), whereas the increase was significant in the control group with a postoperative level of 14.4 ± 4.4 µg/dL (p < 0.001). Among all patients, the SCL was subnormal in 18 patients and within the normal range in 165. Spine surgery was the independent risk factor irrespective of age and sex (odds ratio, 3.472; p = 0.015). CONCLUSIONS: Our results suggest that concern should be raised about the influence of preoperative multiple ESIs on adrenal suppression in spine surgery patients.

Unintentional lumbar facet joint injection guided by fluoroscopy during interlaminar epidural steroid injection: a retrospective analysis

BACKGROUND: An epidural steroid injection (ESI) is a commonly administered procedure in pain clinics. An unintentional lumbar facet joint injection during interlaminar ESI was reported in a previous study, but there has not been much research on the characteristics of an unintentional lumbar facet joint injection. This study illustrated the imaging features of an unintentional lumbar facet joint injection during an interlaminar ESI and analyzed characteristics of patients who underwent this injection. METHODS: From December 2015 to May 2017, we performed 662 lumbar ESIs and we identified 24 cases (21 patients) that underwent a lumbar facet joint injection. We gathered data contrast pattern, needle approach levels and directions, injected facet joint levels and directions, presence of lumbar spine disease as seen on magnetic resonance images (MRI), and histories of lumbar spine surgeries. RESULTS: The contrast pattern in the facet joint has a sigmoid or ovoid contrast pattern confined to the vicinity of the facet joint. The incidence of unintentional lumbar facet joint injection was 3.6%. The mean age was 68.47 years. Among these 21 patients, 14 (66.7%) were injected in the facet joint ipsilaterally to the needle approach. Among the 20 patients who received MRI, all (100%) had central stenosis and 15 patients (75%) had severe stenosis. CONCLUSIONS: When the operator performs an interlaminar ESI on patients with central spinal stenosis, the contrast pattern on the fluoroscopy during interlaminar ESI should be carefully examined to distinguish between the epidural space and facet joint.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Factors Affecting Radiation Exposure during Lumbar Epidural Steroid Injection: A Prospective Study in 759 Patients

OBJECTIVE: To estimate and compare radiation exposure and intervention time during lumbar epidural steroid injection (ESI) 1) under different practitioners and methods with continuous fluoroscopic monitoring, and 2) under one practitioner with different methods and monitoring. MATERIALS AND METHODS: We consecutively recruited 804 patients who underwent lumbar ESI and 759 patients who underwent 922 interventions were included for analysis in this investigation. Three different practitioners (a senior faculty member, junior faculty member, trainee) performed lumbar ESI using different methods (caudal, interlaminar, transforaminal). The senior faculty member performed lumbar ESI under two different methods of fluoroscopic monitoring (continuous [CM] and intermittent monitoring [IM]). The dose area product (DAP) fluoroscopy time, and intervention time during lumbar ESI were compared for 1) ESI methods and practitioners under CM, and 2) ESI methods and monitoring. RESULTS: With CM, interaction between the effects of the practitioner and the intervention on DAP was significant (p < 0.001), but not fluoroscopy time (p = 0.672) or intervention time (p = 0.852). The significant main effects included the practitioner and intervention on DAP, fluoroscopy time, and intervention time with CM (p < 0.001). DAPs and fluoroscopy time for caudal, interlaminar, and transforaminal ESI were higher with CM than with IM (p < 0.001). Intervention time did not differ between CM and IM. CONCLUSION: Radiation exposure is dependent on the practitioners and methods and within the established safety limits during lumbar ESIs under CM. With an experienced practitioner, IM leads to less radiation exposure than CM.

Effect of Cervical Interlaminar Epidural Steroid Injection: Analysis According to the Neck Pain Patterns and MRI Findings

BACKGROUND: It is widely accepted that cervical interlaminar steroid injection (CIESI) is more effective in treating radicular pain than axial neck pain, but without direct comparison. And the differences of effect after CIESI according to MRI findings are inconsistent. In this retrospective study, we evaluated the therapeutic response of CIESI according to pain sites, durations, MRI findings, and other predictive factors altogether, unlike previous studies, which evaluated them separately. METHODS: The medical records of 128 patients who received fluoroscopy guided CIESI were analyzed. We evaluated the therapeutic response (more than a 50% reduction on the visual analog scale [VAS] by their second visit) after CIESI by (1) pain site; neck pain without radicular pain/radicular pain with or without neck pain, (2) pain duration; acute/chronic (more than 6 month), and (3) findings of MRI; herniated intervertebral disc (HIVD)/spinal stenosis, respectively and altogether. RESULTS: Eighty-eight patients (68%) responded to CIESI, and there were no significant differences in demographic data, initial VAS score, or laboratory findings. And there were no significant differences in the response rate relating to pain site, pain duration, or MRI findings, respectively. In additional analysis, acute radicular pain with HIVD patients showed significantly better response than chronic neck pain with spinal stenosis (P = 0.04). CONCLUSIONS: We cannot find any sole predictive factor of therapeutic response to the CIESI. But the patients having acute radicular pain with HIVD showed the best response, and those having other chronic neck pain showed the worst response to CIESI.

Cervical Interlaminar Epidural Steroid Injection for Unilateral Cervical Radiculopathy: Comparison of Midline and Paramedian Approaches for Efficacy

OBJECTIVE: The objective of this study was to compare the clinical outcomes of the cervical interlaminar epidural steroid injection (CIESI) for unilateral radiculopathy by the midline or paramedian approaches and to determine the prognostic factors of CIESI. MATERIALS AND METHODS: We retrospectively analyzed 182 patients who underwent CIESI from January 2009 to December 2012. Inclusion criteria were no previous spinal steroid injection, presence of a cross-sectional image, and presence of follow-up records. Exclusion criteria were patients with bilateral cervical radiculopathy and/or dominant cervical axial pain, combined peripheral neuropathy, and previous cervical spine surgery. Short-term clinical outcomes were evaluated at the first follow-up after CIESI. We compared the clinical outcomes between the midline and paramedian approaches. Possible prognostic factors for the outcome, such as age, gender, duration of radiculopathy, and cause of radiculopathy were also analyzed. RESULTS: Cervical interlaminar epidural steroid injections were effective in 124 of 182 patients (68.1%) at the first follow-up. There was no significant difference in the clinical outcomes of CIESI, between midline (69.6%) and paramedian (63.7%) approaches (p = 0.723). Cause of radiculopathy was the only significant factor affecting the efficacy of CIESI. Patients with disc herniation had significantly better results than patients with neural foraminal stenosis (82.9% vs. 56.0%) (p < 0.001). CONCLUSION: There is no significant difference in treatment efficacy between the midline and paramedian approaches in CIESI, for unilateral radiculopathy. The cause of the radiculopathy is significantly associated with the treatment efficacy; patients with disc herniation experience better pain relief than those with neural foraminal stenosis.

Comparison of Radiation Exposure during Fluoroscopy-Guided Transforaminal Epidural Steroid Injections at Different Vertebral Levels

OBJECTIVE: To estimate and compare radiation exposure during transforaminal fluoroscopy-guided epidural steroid injection (TFESI) at different vertebral levels. MATERIALS AND METHODS: Fluoroscopy-guided TFESI was performed in 181 patients. The patients were categorized into three groups according to the injected lumbosacral nerve level of L2-4, L5, or S1. Fluoroscopy time (FT) and dose area product (DAP) were recorded for all patients; correlations between FT and DAP were determined at each level, and both FT and DAP were compared between the different vertebral levels. RESULTS: The numbers of patients who received ESI at L2-4, L5, and S1 were 29, 123, and 29. Mean FT was 44 seconds at L2-4, 33.5 seconds at L5, and 37.7 seconds at S1. Mean DAP was 138.6 microGy.m2 at L2-4, 100.6 microGy.m2 at L5, and 72.1 microGy.m2 at S1. FT and DAP were positively correlated in each group (p values < 0.001). FT was significantly shorter at L5 than that at L2-4 (p = 0.004) but was not significantly different between S1 and L2-4 or L5 (p values = 0.286 and 0.532, respectively). DAP was significantly smaller at L5 and S1 than that at L2-4, but L5 and S1 were not significantly different. After correcting for FT, DAP was significantly smaller at S1 than that at either L2-4 or L5 (p values = 0.001 and 0.010). CONCLUSION: The radiation dose was small during a single procedure of ESI and showed differences between different lumbosacral spine levels.

Delayed Pneumocephalus Following Fluoroscopy Guided Cervical Interlaminar Epidural Steroid Injection: A Rare Complication and Anatomical Considerations

Cervical epidural steroid injection is indicated for radicular symptoms with or without axial neck pain. Complications are rare but can be serious. Here, we report the case of a 54-year-old man with cervical radicular pain who was treated with cervical epidural steroid injection. Injection was administered twice under fluoroscopic guidance with the loss-of-resistance technique using air to confirm the epidural space. After the second procedure, the patient complained of severe persistent headache and was diagnosed with pneumocephalus on brain computed tomography. The patient returned home without any neurological complication, after a few days of conservative treatment. Though, a fluoroscopic guidance cervical epidural injection is also known to diminish the risk of complications. Physicians should always keep in mind that it does not guarantee safety, particularly in the cervical region, related to its anatomical considerations.

Correlation between Epidurographic Contrast Flow Patterns and Clinical Effectiveness in Chronic Lumbar Discogenic Radicular Pain Treated with Epidural Steroid Injections Via Different Approaches

BACKGROUND: Epidural steroid injections are an accepted procedure for the conservative management of chronic backache caused by lumbar disc pathology. The purpose of this study was to evaluate the epidurographic findings for the midline, transforaminal and parasagittal approaches in lumbar epidural steroid injections, and correlating them with the clinical improvement. METHODS: Sixty chronic lower back pain patients with unilateral radiculitis from a herniated/degenerated disc were enrolled. After screening the patients according to the exclusion criteria and randomly allocating them to 3 groups of 20 patients, fluoroscopic contrast enhanced epidural steroids were injected via midline (group 1), transforaminal (group 2) and parasagittal interlaminar (group 3) approaches at the level of the pathology. The fluoroscopic patterns of the three groups were studied and correlated with the clinical improvement measured by the VAS over the next 3 months; any incidences of complications were recorded. RESULTS: The transforaminal group presented better results in terms of VAS reduction than the midline and parasagittal approach groups (P < 0.05). The epidurography showed a better ventral spread for both the transforaminal (P < 0.001) and the paramedian approaches (P < 0.05), as compared to the midline approach. The nerve root filling was greater in the transforaminal group (P < 0.001) than in the other two groups. The ventral spread of the contrast agent was associated with improvement in the VAS score and this difference was statistically significant in group 1 (P < 0.05), and highly significant in groups 2 and 3 (P < 0.001). In all the groups, any complications observed were transient and minor. CONCLUSIONS: The midline and paramedian approaches are technically easier and statistically comparable, but clinically less efficacious than the transforaminal approach. The incidence of ventral spread and nerve root delineation show a definite correlation with clinical improvement. However, an longer follow-up period is advisable for a better evaluation of the actual outcom.

Epidural steroid injection in spinal pain: a study on the NECA report

Epidural steroid injection (ESI) may be the most widely used interventional procedure in the management of low back pain (LBP). Its use has been supported by more than 45 placebo-controlled studies and dozens of systematic reviews. However the report Pain Reduction Efficacy of Injection Therapy in Chronic LBP by the National Evidence-Based Collaborating Agency (NECA) in 2010 is seen to have mis-concluded that ESI is not effective in the management of chronic LBP. The NECA report contains various descriptive and statistical errors. In this review, we have attempted to correct the errors in the NECA report. We also inform the rationale and evidence of ESI by the review of recent meta-analysis and work to inspire a proper use of ESI in the Republic of Korea.

Correlation between Epidurographic Contrast Flow Patterns and Clinical Effectiveness in Chronic Lumbar Discogenic Radicular Pain Treated with Epidural Steroid Injections Via Different Approaches

BACKGROUND: Epidural steroid injections are an accepted procedure for the conservative management of chronic backache caused by lumbar disc pathology. The purpose of this study was to evaluate the epidurographic findings for the midline, transforaminal and parasagittal approaches in lumbar epidural steroid injections, and correlating them with the clinical improvement. METHODS: Sixty chronic lower back pain patients with unilateral radiculitis from a herniated/degenerated disc were enrolled. After screening the patients according to the exclusion criteria and randomly allocating them to 3 groups of 20 patients, fluoroscopic contrast enhanced epidural steroids were injected via midline (group 1), transforaminal (group 2) and parasagittal interlaminar (group 3) approaches at the level of the pathology. The fluoroscopic patterns of the three groups were studied and correlated with the clinical improvement measured by the VAS over the next 3 months; any incidences of complications were recorded. RESULTS: The transforaminal group presented better results in terms of VAS reduction than the midline and parasagittal approach groups (P < 0.05). The epidurography showed a better ventral spread for both the transforaminal (P < 0.001) and the paramedian approaches (P < 0.05), as compared to the midline approach. The nerve root filling was greater in the transforaminal group (P < 0.001) than in the other two groups. The ventral spread of the contrast agent was associated with improvement in the VAS score and this difference was statistically significant in group 1 (P < 0.05), and highly significant in groups 2 and 3 (P < 0.001). In all the groups, any complications observed were transient and minor. CONCLUSIONS: The midline and paramedian approaches are technically easier and statistically comparable, but clinically less efficacious than the transforaminal approach. The incidence of ventral spread and nerve root delineation show a definite correlation with clinical improvement. However, an longer follow-up period is advisable for a better evaluation of the actual outcom.

Comparison of incidence of intravascular injections during transforaminal epidural steroid injection using different needle types / 대한마취과학회지

BACKGROUND: Infrequent but serious complications of transforaminal epidural steroid injection (TFESI) occur due to inadvertent intravascular injections. A few studies reported that the different needle types can influence on the occurrences of intravascular incidence in TFESI. This study prospectively evaluated whether short-bevel needle can reduce the incidences of intravascular injection of TFESI compared to long-bevel needles. METHODS: From March 2013 to December 2013, 239 consecutive patients were enrolled and received 249 fluoroscopically guided TFESI using the classic technique. Confirmation of intravascular spread was done initially with real time fluoroscopy and then with digital subtraction angiography method in a same patient. Injection technique for TFESI was the same for both short-bevel and long-bevel needle types. RESULTS: The incidences of intravascular injections with the long-bevel and short-bevel needles were 15.0% (21/140) and 9.2% (4/140), respectively. More than half of intravascular injections occurred simultaneously with epidural injections (8.0%, 20/249). There were no statistically significant differences between the long-bevel and the short-bevel needles in the rates of intravascular injections (P = 0.17). CONCLUSIONS: Short-bevel needles did not demonstrate any benefits in reducing the incidence of intravascular injection.

Epidural Steroid Injection in Lumbar Disc Herniation.

Low back pain is a problem that is common and costly to society and its effective management remains a challenge. Major cause of morbidity due to low back pain is prolapsed intervertebral disc which mostly affects young adults in their fourth decade of life. Epidural steroid injection (ESI) is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation. This follow up study was planned to know the results of epidural injections with corticosteroids in symptomatic patients of lumbar disc prolapse. Out of 159 patients who were evaluated before and after the ESI for pain relief, 78% had positive response. No major post-injection complications were reported in this study. Carefully administered epidural steroid injection is a safe and effective modality in the treatment of pain in lumbar disc herniation.

Efficacy of Epidural Neuroplasty Versus Transforaminal Epidural Steroid Injection for the Radiating Pain Caused by a Herniated Lumbar Disc

OBJECTIVE: To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc. METHODS: Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment. RESULTS: In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00+/-1.52, 4.29+/-1.20, 2.64+/-0.93, 1.43+/-0.51 and those of FRI were 23.57+/-3.84, 16.50+/-3.48, 11.43+/-2.44, 7.00+/-2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22+/-2.05, 4.28+/-1.67, 2.56+/-1.04, 1.33+/-0.49 and those of FRI were 22.00+/-6.64, 16.22+/-5.07, 11.56+/-4.18, 8.06+/-1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically. CONCLUSION: Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.

CT guided Epidural Steroid Injection / 신경중재치료의학

PURPOSE: CT guided epidural steroid injection (ESI) is not commonly used for the management of lumbar pain in Korea. Therefore, we evaluated a short term improvement as defined by the scale of pain after CT guided ESI. MATERIALS AND METHODS: We prospectively followed 29 consecutive patients (average age, 62 years; range, 38-78 years; 10 men, 19 women) with lumbar radiculopathy for a minimal follow-up period of 1 month. The intensity of radicular pain was scored by the patient on the visual analog scan (VAS), from 0 (no pain) to 10 (maximal intensity). Scores before and after the procedure were compared by using the Wilcoxon signed-rank test for paired values. Pain relief was classified as "0" when the pain was completely resolved or had diminished, "1" for not changing, "2" for an increase in pain. RESULTS: The mean VAS scores were 8 (range, 2-10) before and 5 (range, 1-10) 1 month after the procedure, with significant pain relief (p < .001). Pain relief was divided as 0 in 21 patients (72%), 1 in 8 patients (28%) without anyone of grade 2. There was no procedure-related complication except one patient with temporary left side weakness and sensory change which lasted 1-2 hours and subsided thereafter propably due to temporary route compression caused by previous postoperative adhesion or inadvertent intrathecal injection. CONCLUSION: Good pain relief can be expected after CT guided ESI. CT guided ESI may have some difficulties in postoperative patient with metal devices or adhesion.

Effect of Intensive Conservative Treatment on Extraforaminal Lumbar Disc Herniations - 1 Year Prospective Follow-up Study

OBJECTIVE: To evaluate the outcomes of intensive conservative treatment on extraforaminal lumbar disc herniations. METHOD: Twenty five patients with extraforaminal lumbar disc herniations with symptomatic radicular pain were included. Under fluoroscopic guidance, 40 mg of triamcinolone was infused around the nerve root after provocation of patient's usual radicular pain. Lumbosacral dynamic stabilization exercise, thermal and electrical therapy, and education of posture correction were added. The clinical outcomes were measured by visual analogue scale (VAS) and Oswestry disability index (ODI) before treatment, one, three, six, and twelve months after the treatment. After twelve months, patients' satisfaction was classified to four categories: excellent, good, fair, or poor. Four patients were dropped out. RESULTS: Follow-up VAS and ODI significantly decreased since post-treatment one month (p<0.0001). The average score of VAS for lower extremity and back pain reduced significantly from 6.6, 4.5 at pretreatment to 1.5, 1.9 at 12 months post-treatment, respectively (p<0.0001). The averages of ODI reduced significantly from 65.4% at pretreatment to 25.4% at post-treatment 12 months (p<0.0001). In patients' satisfaction, seventeen patients (81.0%) were recorded as excellent or good after post-treatment 12 months. CONCLUSION: Intensive conservative treatment was effective on patients who underwent extraforaminal lumbar disc herniation. Pain relief and functional improvement sustained for 12 months.

Symptomatic Spinal Epidural Lipomatosis Induced by Repeated Epidural Steroid Injections

We present a very rare case of symptomatic spinal epidural lipomatosis(SEL) induced by repeated epidural steroid injections. A 59-year-old woman presented with severe neurogenic claudication and bilateral radiating leg pain aggravated for 1 year. She had undergone epidural triamcinolone injections 19 times for 3 years in a local clinic for chronic low back pain. At first, there had been no symptoms of lumbar stenosis such as leg pain or claudication. During the period of injections, radiating leg pain and claudication appeared newly and were gradually aggravated. Hormonal study and physical examination confirmed iatrogenic Cushing's syndrome. Magnetic resonance imaging(MRI) revealed extensive epidural fat deposition compressing cauda equnina from L3 to S1. Therefore, we concluded that multiple epidural steroid injections caused iatrogenic Cushing's syndrome and SEL. We performed debulking of epidural fat and bilateral neural decompression via left unilateral partial hemilaminectomy at L3-4-5-S1 in order to preserve stability considering preexisting multiple compression fractures. After operation, the patient's neurogenic claudication and radiating pain were completely disappeared.

Assessment of successful epidural steroid injection using photoplethysmogram

BACKGROUND:One of effective treatment methods for back pain and radiculopathy is epidural steroid injection (ESI). However, its effectiveness is hard to judge.So, it is strongly urged to develop a method to evaluate the proper injection of ESI. Photoplethysmogram (PPG) is known as a technique to measure blood oxygen saturation. We were intended to study the PPG for the evaluation of the ESI instantaneously. METHODS:All patients were explained for the study protocol to get informed consent.Twenty volunteers were recruited for this study and four of them were allocated in one of 5 ESI levels; L2-3, L3-4, L4-5, L5-S1 and caudal.They were in the lateral position with 4 PPG probes in their both 2nd fingers and 2nd toes.The PPG signals were collected to a device and converted digitally.PPG signal has two components, total absorbance (TA) and oscillating pulse component (OPC).We compared the both toe PPG signals before and after ESI based on the finger PPG. RESULTS:TA changed in 60% of ESI volunteers and L4-L5 and L5-S1 groups had high change rate compared to L2-L3 group.Also, the symptom relief rate of TA and OPC change volunteers of L4-L5 and L5-S1 were 100% but other level had variable relief rate. CONCLUSIONS:It is possible to use the PPG signal to predict ESI success based appropriate signal change.It is also needed to develop other level signal detection method and to modify appropriate guideline for the decision of change of PPG.