Should We Cease Performing Transforaminal Injections?

Raghavendra, Meda; Patel, Vikram

doi:10.1097/00115550-200503000-00014

Cited by 5 publications

(3 citation statements)

References 8 publications

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“…The causes of back pain are mainly spinal stenosis, spondylosis, or disc herniation. The effects of epidural steroid injection tend to be temporary and the duration is smaller that in case of the transforaminal access (Botwin and Gruber, 2003; Raghavendra and Patel, 2005).…”

Section: Translaminar Approachmentioning

confidence: 98%

“…This technique is useful as diagnostic and therapeutic tool in patients with radicular pain, caused more frequently by disc herniation and foraminal stenosis (Botwin and Gruber, 2003; Raghavendra and Patel, 2005). It is used also when more than one disc is involved or when the information obtained by the electromyogram (EMG) affects to two o more nerve roots, to differentiate which disc is causing the symptoms.…”

Section: Transforaminal Approachmentioning

confidence: 99%

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Transforaminal or translaminar approach for dorsal root ganglion and dorsal nerve root. Anatomical reason for technique decision

Reina

Andrés

Hernández

et al. 2010

Eur Journal of Pain Supp

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Radiculopathy is probably one of the most frequent types of pain seen in Pain Clinics. Invasive techniques such as transforaminal or translaminar injections are used when other conservative methods have failed. In these procedures, medication such as corticosteroids and local anaesthetics are injected next to the dorsal root ganglion and dorsal nerve root. The decision to use one or another approach depends on factors such as the region to treat (cervical, dorsal or lumbar), the characteristics and the cause of the pain. In this study we review the anatomical and histological aspects that can influence the decision to use each of these techniques for the treatment of radicular pain. We describe the morphology of the intervertebral foramen, its dimensions and the vascular supply of spinal cord and intervertebral foramen. We also analyze ultrastructural details that may help understand the role of spinal nerve root cuffs and other structures such as capillaries and fat that plays an important role on the spread of substances injected in the epidural space and in transforaminal blockade. This review includes a microscopic analysis of the corticosteroids used and in some cases related to the complications published.

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Section: Translaminar Approachmentioning

confidence: 98%

Section: Transforaminal Approachmentioning

confidence: 99%

Transforaminal or translaminar approach for dorsal root ganglion and dorsal nerve root. Anatomical reason for technique decision

Reina

Andrés

Hernández

et al. 2010

Eur Journal of Pain Supp

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“…Theoretically, particulate steroids seem to be more efficacious than nonparticulate steroids. Some have advocated measures like using digital subtraction, dye injection using real time fluoroscopy, using blunt needles, and using test doses before injecting steroid (15,208). One case of paralysis has been reported in spite of using a test dose and digital subtraction (95).…”

Section: Inadequate Literature Reviewmentioning

confidence: 99%

Epidural Steroid Warning Controversy Still Dogging FDA

Manchikanti

Kd²,

Singh³

et al. 2014

Pain Phys

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On April 23, 2014, the Food and Drug Administration (FDA) issued a letter of warning that injection of corticosteroids into the epidural space of the spine may result in rare, but serious adverse events, including “loss of vision, stroke, paralysis, and death.” The advisory also advocated that patients should discuss the benefits and risks of epidural corticosteroid injections with their health care professionals, along with the benefits and risks associated with other possible treatments. In addition, the FDA stated that the effectiveness and safety of the corticosteroids for epidural use have not been established, and the FDA has not approved corticosteroids for such use. To raise awareness of the risks of epidural corticosteroid injections in the medical community, the FDA’s Safe Use Initiative convened a panel of experts including pain management experts to help define the techniques for such injections with the aim of reducing preventable harm. The panel was unable to reach an agreement on 20 proposed items related to technical aspects of performing epidural injections. Subsequently, the FDA issued the above referenced warning and a notice that a panel will be convened in November 2014. This review assesses the inaccuracies of the warning and critically analyzes the available literature. The literature has been assessed in reference to alternate techniques and an understanding of the risk factors when performing transforaminal epidural injections in the cervical, thoracic, and lumbar regions, ultimately resulting in improved safety. The results of this review show the efficacy of epidural injections, with or without steroids, in a multitude of spinal ailments utilizing caudal, cervical, thoracic, and lumbar interlaminar approaches as well as lumbar transforaminal epidural injections . The evidence also shows the superiority of steroids in managing lumbar disc herniation utilizing caudal and lumbar interlaminar approaches without any significant difference as compared to transforaminal approaches, either with local anesthetic alone or local anesthetic and steroids combined. In conclusion, the authors request that the FDA modify the warning based on the evidence. Key words: Chronic pain, epidural injections, epidural steroids, local anesthetic, radicular artery, complication.

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