Treatment Gaps and Emerging Therapies in Lumbar Disc Herniation

Objective: Since inflammation plays an important role in radiculopathies, and that neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratios (PLR) are known to be associated with inflammation, the effects of these values on transforaminal epidural steroid injections (TFESI) in patients with lumbar radiculopathy were investigated. Methods: A total of 101 patients, who were diagnosed with lumbar radiculopathy and underwent TFESI, were retrospectively analyzed. Therapeutic success was considered to be a ≥ 50% decrease in visual analog scale (VAS) scores one month after TFESI. The patients in the study were placed in two groups according to whether their treatment was successful or unsuccessful, according to this criteria, and hemogram parameters in the two groups were then compared. Results: The study included 46 female and 55 male patients with a mean age of 49.43 ± 13.29. The median duration of symptoms was 3.0 (3.0-8.0) months. It was found that there was no significant difference between the groups in terms of neutrophil, lymphocyte, monocyte, platelet counts, mean plazma volümü (MPV), kırmızı hücre dağılım genişliği (RDW), platelet/ lenfosit oranı (PLR), sistemik inflamatuar indeks (SII), sedimentation, and C-reactive protein (CRP), although it was observed that there were significant increases in NLR in the successful group [2.34 (1.70-3.17)], as compared to the unsuccessful group [1.79 (1.51-2.57)] (p=0.026). Conclusion: Neutrophil/lymphocyte ratio is able to predict the response to TFESI treatment in patients with lumbar radiculopathy, in that patients with a higher NLR demonstrate a better response. Keywords: Hemogram parameters, inflammation, neutrophil to lymphocyte ratio, lumbar disc herniation, lumbar radiculopathy

Phantom Radiculopathy: Case Report and Review of the Literature

Comparison of Epidural Steroid Injection Efficiency with Two Different Doses in Radiculopathies Associated with Lumbar Disc Herniation

The aim of this retrospective study was to investigate the therapeutic effect of transforaminal epidural steroid injection in patients with chronic low back pain and radicular leg pain due to lumbar disc herniation. This study included 80 patients (32 female and 48 male; mean age: 45.8 years [range: 25-65 years]) that received fluoroscopically guided transforaminal epidural steroid injections for chronic radicular low back pain due to lumbar disc herniation. All of the patients had diagnostic MRI findings and did not respond to conservative treatment. All injections were performed by the same physician at the interventional pain unit of a tertiary hospital. The effectiveness of transforaminal epidural steroid injections was assessed via a standardized telephone questionnaire administered 2 years after the first injection. Mean duration of radicular low back pain was 24.50 ± 18.25 months. Most of the epidural injections were administered at the L5 and S1 levels. The most effective post-injection period was the first 5.11 ± 3.07 months. Mean duration of injection effect was 12.46 ± 7.24 months. The response rate to the epidural steroid injections was 72%. There was negative correlation between the duration of treatment effect and the duration of pre-treatment symptoms. Additionally, clinical improvement of radicular low back pain increased significantly as the duration of pre-treatment symptoms decreased. Based on the present findings, we think that transforaminal epidural steroid injections can be used as an alternative treatment for managing chronic radicular low back pain.

The treatment of persistent lumbar radicular pain (LRP) by CT-guided epidural steroid injection (ESI) is extensively used and associated with rare but serious complications. Platelet-rich plasma (PRP), which has recently been shown to favor healing and the anti-inflammatory process by delivering growth factors and cytokines, might be an alternative and potentially safer option. We compared the efficacy of interlaminar CT-guided epidural PRP injections (EPRPI) and ESI in the treatment of persistent LRP (> 6weeks). In this non-randomized comparative study, patients were prospectively assessed for pain using the numerical rating scale (NRS) and for function with the Oswestry Disability Index (ODI) before and 6weeks after treatment. Related paired and independent t tests were used for intra- and inter-group comparisons. A total of 60 patients were included in 2 groups (n = 30 EPRPI, n = 30 ESI). A statistically significant improvement was found in both groups at 6weeks (mean NRS values 5.7 (± 2.36) at D0 and 3.7 (± 2.3) at 6weeks (p < 0.01); mean ODI values 30 (± 11) at D0 and 21 (± 13) at 6weeks (p < 0.01)). No significant difference was observed in the decrease in NRS and ODI scores between the 2 groups at 6weeks (p = 0.848 and p = 0.314 for the NRS and ODI, respectively). No major complications were noted. The results of CT-guided interlaminar EPRPI are similar to ESI for the treatment of persistent LRP and could be a safer option. • Treatment of persistent lumbar radicular pain by CT-guided epidural steroid injections is associated with rare but serious complications. • By promoting an anti-inflammatory process, epidural platelet-rich plasma injections might be an alternative treatment of persistent radicular pain. • Platelet-rich plasma CT-guided epidural injections are similar to steroid for the treatment of lumbar radicular pain at 6weeks post-procedure and could be a safer option.

Background:Epidural steroid injection (ESI) has been used in managing chronic radicular pain. Regarding various techniques of ESI, the synergistic effect of caudal ESI (CESI) on transforaminal ESI (TFESI) in chronic lumbosacral radicular pain in prospective randomized controlled trial has not been determined. Methods: A total of 54 eligible patients with lumbosacral radicular pain were randomly allocated to undergo TFESI plus CESI (TC group) or TFESI alone (T group). The effective response to treatment was predefined by at least a 30% reduced verbal numerical rating scale (VNRS) from baseline between group comparison and the functional outcomes as measured by improved Oswestry Disability Index by least 15 points from baseline. All participants were evaluated using a single blinded outcome assessor before the procedure and at 1, 3 and 6 months after the procedure. P <0.05 was considered as statistically significant. Results: Average VNRS reduced significantly from baseline after receiving procedure at 1, 3 and 6 months in both groups (P-value <0.05). The TC group exhibited more effective and showed significant pain relief compared with the T group at 3 months (P=0.01). However, no statistical difference was observed between sub group analysis in pain relief and insignificant difference between group comparisons of functional outcomes. Conclusions: A treatment combining TFESI and CESI showed significant pain relief over TFESI alone at 3 months. No effect was found concerning functional evaluation. Registration:Thai Clinical Trials Registry IDTCTR2017110100201/11/2017F.

Lumbar intraspinal synovial cysts: conservative management and review of the world's literature

Epidural steroid injections are commonly used for chronic spinal pain. However, there is no conclusive evidence regarding their effectiveness, and debate continues as to their value in managing chronic spinal pain. To evaluate various types of epidural injections (interlaminar, transforaminal, and caudal) for managing chronic spinal pain (axial and radicular). A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of the Cochrane Musculoskeletal Review Group for randomized trials. Data sources included relevant English literature identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed for trials with different control groups, with different modes of epidurals (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). The primary outcome measure was pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement was defined as less than 6 weeks, and long-term improvement was defined as 6 weeks or longer. For lumbar radicular pain with interlaminar lumbar epidural steroid injections, the level of evidence was strong for short-term relief and limited for long-term relief. For cervical radicular pain with cervical interlaminar epidural steroid injections, the evidence was moderate. The evidence for lumbar transforaminal epidural steroid injections for lumbar nerve root pain was strong for short-term and moderate for long term improvement. The evidence for cervical transforaminal epidural steroid injections for cervical nerve root pain was moderate. The evidence was limited for lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief. For managing chronic postlumbar laminectomy syndrome and spinal stenosis the evidence was limited for low back and radicular pain. The evidence was moderate for chronic low back pain. The evidence for effectiveness of epidural injections in managing chronic spinal pain ranged from limited to strong.

IntroductionThis study is to compare advantages, safety and mid-term effects of fluoroscopy (FL)-guided transforaminal (TF) to caudal (CA) epidural steroid injection (ESI) for chronic pain after spinal surgery (CPSS) by assessing pain relief and improvement of functionality.MethodsPatients with radicular pain in CPSS who received FL-guided CA (n = 21) or TF (n = 28) ESI were included in this retrospective study. Complication frequencies, adverse events, treatment effects, and functional improvements for each procedure were compared at 1, 3, and 6 months following the last injection.ResultsBoth the Oswestry Disability Index (ODI) and verbal numeric pain scale scores (VNS) demonstrated improvement in both groups at all 1, 3, and 6 months following the last injection, without meaningful difference between groups (p < 0.05). Moreover, no meaningful difference was present between groups in terms of treatment success rate at every time point. The amount of time used for the injection procedure was shorter in CA group than in TF group (410.32 ± 25.73 seconds vs 640.65 ± 18.03 seconds, p < 0.05). Within 2 weeks of the injection treatment, the patient satisfactory scores were evaluated, with excellent being rated 85.7% (n = 18) among CA-ESI patients and 55.7% (n = 16) among TF-ESI patients (p < 0.05). Logistic regression analysis revealed that variables such as method of injection (CA or TF approach), sex, use of analgesics, pain duration, number of injections, and age were not significant variables for successful treatment results. There were no adverse complications after the procedure in both groups.ConclusionThe outcomes of FL-guided CA-ESI and TF-ESI for CPSS are similar in terms of pain reduction and functional improvements. CA-ESI is associated with lesser procedure time. In addition, compared with the TF-ESI, the patient experiences less discomfort during the injection, and the satisfaction with the injection treatment is confirmed to be better. Accordingly, both methods are effective; however, in the CA approach, patient satisfaction is higher and the procedure time is shorter.

Background: The variant course of the right iliac vein between the right psoas muscle and spine and its significance has not been reported and lumbosacral radiculopathy is not a known complication after occlusion of the right iliac vein stent in such condition. Case Report: The patient is a 38-year-old woman with Factor V Leiden mutation, multiple deep vein thrombosis, including in her bilateral iliac veins, and a variant course of the right iliac vein between the psoas muscle and spine, who presented with radicular pain and weakness after stenting of the bilateral iliac veins. She was found to have complete occlusion of the right common iliac through the femoral vein stent that was compressing her lumbosacral spinal roots and resulted in lumbosacral radiculopathy. Her pain and weakness significantly improved after an epidural steroid injection. Conclusion: Lumbosacral radiculopathy is a rare complication after occlusion of the right iliac vein stenting in the setting of a variant course of the right common iliac vein between the psoas muscle and spine and Factor V Leiden mutation. The risks and benefits of implanting a kissing stent in a similar scenario should be weighed carefully for patients at high risk for stent occlusion. Additionally, patients should be assessed for variable anatomy as part of the presurgical workup to hopefully prevent this undesired outcome. Key words: Lumbosacral radiculopathy, iliac vein stenting, Factor V Leiden, deep venous thrombosis, variant course

Although the comparative efficacy of particulate vs. nonparticulate steroids for the treatment of radicular pain with transforaminal epidural steroid injection has been investigated, there is minimal literature comparing particulate steroids. The authors aimed to determine whether transforaminal epidural steroid injection with triamcinolone or betamethasone, two particulate corticosteroids, more effectively reduces lumbosacral radicular pain. This is a longitudinal cohort study of 1021 patients (1568 transforaminal epidural steroid injections) who received betamethasone or triamcinolone between January 2006 and October 2007 in an academic spine center. The frequency of greater than 50% pain reduction was compared between groups. This study included 42.4% (433) male and 57.6% (588) female patients, with a mean (SD) age of 54.1 (16.7) yrs. Betamethasone and triamcinolone were used in 78.8% (1235) and 21.2% (333) of subjects, respectively. Significantly more patients who received triamcinolone (44.4% [95% confidence interval, 36.2%-52.8%]) experienced greater than 50% pain reduction at short-term follow-up (1-4 wks) compared with patients who received betamethasone (26.8% [95% confidence interval, 22.7%-31.4%]). Patients who received transforaminal epidural steroid injection with triamcinolone reported more frequent pain relief of greater than 50% at short-term follow-up compared with those who received betamethasone. These findings further develop the literature on comparative effectiveness in epidural steroid injections. However, given the exploratory and retrospective nature of this investigation, further study is needed.

The Basis for Recommending Repeating Epidural Steroid Injections for Radicular Low Back Pain: A Literature Review

Background: Chronic radicular low back pain is a common disease that limits patient’s daily activity. Epidural steroid injection is becoming the mainstay of therapies for radicular low back pain due to contained bulged disc. Purpose: To determine the effect of adding hypertonic saline to epidural steroid injections to provide pain relief for chronic radiculopathy back pain secondary to foraminal stenosis. Methods: In a randomized clinical trial, 50 patients with unilateral radicular low back pain due to unilateral foraminal stenosis were enrolled. Epidural steroid injections were performed using transforminal approach. In hypertonic saline group 80 mg of triamcinolone plus 2 ml of 10% hypertonic saline, and in control group 80 mg of triamcinolone plus 2 ml of normal saline were injected. Outcome measures were numerical rating scale (NRS), Oswestry disability index, and proportion of responder patients (NRS<3) were measured at baseline, 1, 3, and 6 months post-procedure. Results: Comparison of pain score between two groups showed that pain score was not significantly different at 1 (p=0.24), 3 (p=0.31) and 6 month (p=0.38). Significant pain relief (NRS<3) in 76% of patients within 1 months. Percent of patient with NRS<3 was 48% and 32% in hypertonic and 40% and 32% in steroid group at 3 and 6 month, respectively. Conclusion: Hypertonic saline added to steroid did not significantly increase pain relief effect of epidural steroid injection.

Excessive spine operations is an economic and social problem today in Korea. Proper conservative treatment can reduce the need for surgical treatment by relieving the pain during the acute phase of spinal disease. Epidural steroid injection and a selective nerve root block are relatively safer and easier than other treatments. They may have many advantages such as relief of neck and back pain and of radicular pain, and reducing the gastrointestinal adverse effects caused by long-term NSAID medication or injection. Furthermore, patients in an inoperable state due to old age or other comorbidities and outpatients who want conservative treatment may benefit from epidural steroid injection and a nerve root block. The treatment outcomes differ among reports. The efficacy of temporary pain relief has been described to be excellent, but it gradually decreases as time passes. Recently, transforaminal epidural steroid injection has been widely performed. Epidural steroid injection should be performed for temporary pain relief due to its limited efficacy. In addition, an overuse of epidural and selective nerve root steroid injection can cause serious side effects. Therefore, this procedure should be done with caution, taking into account the technical risks and side effects.

205. Can imaging characteristics on MRI predict the acuity of a lumbar disc herniation?