The Effectiveness of Transforaminal Versus Caudal Routes for Epidural Steroid Injections in Managing Lumbosacral Radicular Pain

Liu, Jun; Zhou, Hengxing; Lu, Lu; Li, Xueying; Jia, Junya; Shi, Zhongju; Yao, Xuemei; Wu, Qiuli; Feng, Shiqing

doi:10.1097/md.0000000000003373

Cited by 41 publications

(28 citation statements)

References 53 publications

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“…Because axial back or radicular leg pain is mainly generated from sinuvertebral nerves existing in the ventral epidural space, the nerve root sheath and the dorsal root ganglion, the main target of drug administration is logically considered the ventral epidural spread rather than the dorsal epidural space (3,4). Hence, TFEI is preferred by some physicians because it delivers the medication directly into the ventral epidural space (5)(6)(7)(8), whereas, ILEI delivers the medication into the posterior epidural spaces under the expectation that the administered medication ideally spreads to the ventral spaces afterward (9)(10)(11)(12).…”

Section: Data Collectionmentioning

confidence: 99%

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Lee

2018

Pain Phys

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Background: Epidural injection (EI) is used to treat back or radicular pain from lumbosacral disc herniation (LDH). Although several reports have stated that the transforaminal approach in EI (TFEI) has an advantage in target specificity and yields better clinical efficacy than the interlaminar approach in EI (ILEI), other studies have indicated that the clinical efficacy of ILEI was not inferior to that of TFEI and that ILEI also has the ability to spread medication into the ventral space to a degree similar to that of TFEI. There has been controversy about whether TFEI is superior to ILEI in clinical efficacy. Objectives: This systematic review and meta-analysis aimed to investigate whether TFEI is more useful than ILEI for achieving clinical outcomes in patients with LDH. Study design: A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCT). Methods: A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From those found fulfilling the search criteria, manuscripts that compared the clinical efficacy of steroids and control agents, such as local anesthetics or saline, in terms of pain control and functional improvement were included in this study. Exclusion criteria included a previous history of lumbosacral surgery, nonspecific low back pain, severe spinal stenosis, and severe disc degeneration. After reviewing titles, abstracts, and the full text of 6,711 studies; 12 studies were included in the qualitative synthesis. Data including pain scores, functional scores, and follow-up period were extracted from 10 studies and analyzed using a random effects model to obtain effect size and its statistical significance. The quality and level of evidence were analyzed in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Results: In terms of pain control, TFEI showed significantly better short-term (2 weeks to 1 month) outcomes and slightly favorable long-term (4 - 6 month) outcomes, but without significance, in comparison with ILEI. In terms of functional improvement, TFEI also showed favorable short- and long-term outcomes, but without significance, in comparison with ILEI. TFEI had target specificity, required no additional cost and resources, and had equal applicability to ILEI. However, TFEI was more associated with a higher frequency of discomfort or adverse events during the procedure. Overall, better results were reported with TFEI over ILEI, but with low-grade evidence due to the inconsistency and imprecision of the selected studies. Limitation: Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies. Conclusions: Based on low-grade evidence, TFEI showed significantly better short-term pain control and slightly favorable outcomes in long-term pain reduction and short- and long-term functional improvement in comparison with ILEI. Key words: Epidural injection, interlaminar, transforaminal, meta-analysis, systemic review, pain, function

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Section: Data Collectionmentioning

confidence: 99%

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Lee

2018

Pain Phys

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“…Transforaminal epidural injection (TFEI) is an effective modality in managing lumbosacral radicular pain. 1,2 It has the advantage of delivering medications, including local anesthetics or steroids, to areas closest to pain generators in the anterior epidural space; hence, it is more efficient in relieving pain than the caudal or interlaminar approach. 3 Since the drugs can be injected directly around the nerve root through the intervertebral foramen, this method can be used as either diagnostic or therapeutic selective nerve blocks.…”

Section: Introductionmentioning

confidence: 99%

<p>Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin’s Triangle Approach</p>

Lee¹,

Jo²,

Song³

et al. 2020

JPR

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Purpose Dispersion of contrast media into the anterior epidural space is correlated with better outcomes after transforaminal epidural injection (TFEI). Needle tip position is an important factor affecting the pattern of contrast media dispersion. It is difficult to advance the needle medially to the interpedicle line with a conventional approach, especially in a severe spinal stenosis. But, with Kambin’s triangle approach, the needle can be advanced more medially even in the severe stenosis. We aimed to compare contrast media dispersion patterns according to the needle tip position in TFEI with Kambin’s triangle approach. Patients and Methods This single-center retrospective study analyzed fluoroscopic data of patients who underwent TFEI from March 2019 to July 2019. Data on the history of lumbar spinal fusion surgery and MRI findings were collected. The needle tip position was evaluated in three positions on fluoroscopic images (final anteroposterior [AP] view): extraforaminal (EF), lateral foramen (LF), and medial foramen (MF). Contrast media dispersion into the epidural space (epidural pattern) in the AP view was evaluated as a dependent variable. The relationship between the contrast media dispersion pattern and needle tip position was analyzed, and other factors affecting the contrast media dispersion pattern were identified. Results Ninety-eight TFEI cases were analyzed (51 LF, 35 MF, and 12 EF). An epidural pattern of dispersion was observed more frequently in the LF and MF groups than in the EF group. The LF and MF groups showed no significant difference in epidural pattern frequency. On logistic regression analysis, needle tip position emerged as a major factor influencing epidural pattern, while other factors including spine conditions had no significant effect. Conclusion Positioning the needle tip medial to the pedicle helps in the spread of the contrast media into the epidural space during TFEI with Kambin’s approach. Factors other than the needle tip position did not significantly affect the contrast media dispersion pattern.

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“…LESIs deliver steroids into the epidural space, in the aim to reduce inflammation around – and/or compression on – lumbar nerve roots 3. Technically, they are performed under fluoroscopic guidance via interlaminar, transforaminal, or caudal approaches; each has advantages and disadvantages 4. Regardless of the approach used, LESIs are generally considered as relatively safe procedures.…”

Section: Introductionmentioning

confidence: 99%

“…Symptoms include headache, soreness at the injection site, and transient toxicity. Seldom, more serious complication may occur such as hemorrhage, infection, trauma to a nerve root, or paraplegia due to arterial occlusion associated with injection of particulate steroids 4–6. In 2014 the Food and Drug Administration (FDA) issued a briefing document on ESIs, which included cases of serious neurologic adverse events caused by arachnoiditis 7.…”

Section: Introductionmentioning

confidence: 99%

<p>Adhesive arachnoiditis following lumbar epidural steroid injections: a report of two cases and review of the literature</p>

Eisenberg¹,

Goldman²,

Schlag-Eisenberg³

et al. 2019

JPR

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Lumbar epidural steroid injections (LESIs) are commonly used for managing lower back pain (LBP) and radicular pain. LESIs are generally considered safe with only rare serious complication. One very rare complication that is frequently cited in the literature is adhesive arachnoiditis. However, a literature search failed to detect even one published manuscript, clearly documenting LESI induced arachnoiditis. This article presents two patients who received a transforaminal L5–S1 and two L3–L4 interlaminar LESIs. Although the presented patients developed clear radiological (MRI) findings of arachnoiditis, they were not accompanied by any improvement or deterioration in their clinical condition. The article also reviews the literature on the prevalence, pathogenesis, diagnosis, and clinical features of adhesive arachnoiditis. Literature suggests that adhesive arachnoiditis following LESIs is a rare entity, which – as seen in our patients – has clear radiological characteristics but uncertain pathogenesis. It has a large spectrum of clinical presentation, ranging from an incidental finding to a serious neurological sequela. In at least some patients with adhesive arachnoiditis following LESI, the radiological and clinical findings may fail to correlate with each other. In light of the fact that LESI is one of the most commonly performed procedures for managing LBP, clinicians should be aware of this rare yet existing entity.

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The Effectiveness of Transforaminal Versus Caudal Routes for Epidural Steroid Injections in Managing Lumbosacral Radicular Pain

Cited by 41 publications

References 53 publications

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis

<p>Effect of Needle Tip Position on Contrast Media Dispersion Pattern in Transforaminal Epidural Injection Using Kambin’s Triangle Approach</p>

<p>Adhesive arachnoiditis following lumbar epidural steroid injections: a report of two cases and review of the literature</p>

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