scholarly journals Needle Position Analysis in Cases of Paralysis From Transforaminal Epidurals: Consider Alternative Approaches to Traditional Technique

2013 ◽  
Vol 4;16 (4;7) ◽  
pp. 321-334
Author(s):  
Sairam Atluri
Keyword(s):  
Anterior Part ◽  
Epidural Injection ◽  
Neural Foramen ◽  
Steroid Injections ◽  
Position Analysis ◽  
Epidural Steroid Injections ◽  
Superior Part ◽  
Traditional Technique ◽  
Needle Position ◽  
Epidural Steroid

Background: Transforaminal technique for epidural steroid injections, unlike other approaches, is uniquely associated with permanent, bilateral, lower extremity paralysis. Objective: To review the literature and analyze the reported cases of paralysis from lumbar transforaminal epidural steroid injections to possibly establish a cause and to prevent this complication. Study Design: Eighteen cases of paralysis from transforaminal epidural injection have been reported. We could analyze the position of the needle within the neural foramen based on the available images and/or description among 10 of these 18 cases. Five cases were performed with computed tomography guidance and 12 cases were performed with fluoroscopic guidance [unknown in one case]. Additionally, other variables associated with the procedure, including the technique, were also examined. Methods: Analysis of the needle position in the neural foramen in cases of paralysis from transforaminal epidural steroid injections. This analysis is based on images and/or description provided in published reports. Results: Paralysis in these cases seems to be associated with a well performed traditional safe triangle approach with good epidural contrast spreads. Analyzed data shows that 77.7% of the time, the needle was in the superior part of the foramen. In 71.4% of the cases, the needle was in the anterior part of the foramen. This coincides with the location of the radicular artery in the foramen. In 22.2%, the needle was in the midzone (neither in the superior nor inferior zone). No level was spared as this event occurred at every foramen from T12 to S1. Ten of these events happened during a left-sided procedure and 8 during a right-sided procedure. No relation to this complication was noted when other variables like type and size of the needles, side of the injection, local anesthetic, contrast, or volume of injectate were taken into consideration. Limitations: Only 18 cases of paralysis from transforaminal epidurals have been reported. Out of these, only 10 cases included images or descriptions which could be evaluated for our study. Conclusion: In light of the anatomical and radiological evidence in the literature that radicular arteries dwell in the superior part of the foramen and along with our needle position analysis, we suggest that the traditional technique of placing the needle in the superior and anterior part of the foramen must be reexamined. Alternative, safer techniques must be considered, one of which is described. Key words: Lumbar epidural injection, lumbar transforaminal, approach, selective nerve root block, paralysis, steroid, particulate, nonparticulate, safe triangle, radicular artery, artery of Adamkiewicz

scholarly journals Contrast Flow Selectivity During Transforaminal Lumbosacral Epidural Steroid Injections

2008 ◽  
Vol 6;11 (12;6) ◽  
pp. 855-861
Author(s):  
Michael B. Furman
Keyword(s):  
Epidural Space ◽  
Nerve Root ◽  
Lumbar Disc ◽  
Human Study ◽  
Contralateral Side ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Needle Position ◽  
Epidural Steroid ◽  
Contrast Flow

Background: Lumbosacral transforaminal epidural steroid injections (LS-TFESIs) are an accepted procedure used in the comprehensive, conservative care for lumbar disc pathology and/or spinal stenosis induced low back pain with a radicular component. Historically, the terminology used to describe the transforaminal technique of instilling medications into the epidural space and/or exiting structures has varied. These procedures have also been referred to as either diagnostic or therapeutic selective nerve root blocks (SNRBs). Although this procedure is typically used to “selectively” treat isolated pathology, the “SNRB” terminology suggests that one can selectively diagnose or treat a specific nerve root as a pain generator by anesthetizing or blocking it. It has been recently demonstrated that L4 and L5 SNRBs are often non-“selective” by investigating the extent of epidural contrast flow patterns after injecting 1.0 mL of contrast. Our study attempts to identify the minimum injectate volume at which LS-TFESIs may still be considered “selective” with no injectate extending to either the adjacent (superior and/or inferior) levels or to the contralateral side. Objective: Quantitatively evaluate contrast flow level selectivity noted during fluoroscopically guided lumbosacral transforaminal epidural steroid injections (LS-TFESIs). Study Design: Prospective, nonrandomized, observational human study. Methods: Thirty patients (female = 10, male = 20) undergoing LS-TFESIs were investigated. After confirming appropriate spinal needle position with biplanar imaging, 4.0 mL of nonionic contrast was slowly injected. Fluoroscopic images were recorded at 0.5 mL increments. These biplanar contrast flow images were evaluated to determine which 0.5 mL volume increment was no longer specific for the injected level. In particular, we documented when contrast extended either to a superior or inferior spinal segment or crossed the midline spine to the contralateral side. Results: After injecting 0.5 mL of contrast, 30% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.0 mL of contrast, 67% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.5 mL of contrast, 87% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 2.5 mL of contrast, 90% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. Conclusions: Diagnostic LS-TFESI or SNRB blocks limiting injectate to a single, ipsilateral segmental level cannot reliably be considered diagnostically selective with volumes exceeding 0.5mL. Injectate volumes greater than 0.5mL are consistently non-selective and cannot be used reliably for diagnostic block procedures in the epidural space. Key words: Epidural steroid injections, selective nerve root block, transforaminal, contrast flow

scholarly journals Efficacy of epidural injection of steroid in treatment of lumber disc prolapse: article review

2021 ◽  
Vol 8 (1) ◽  
pp. 10-19
Author(s):  
Musaed hekmat AL-Dahhan
Keyword(s):  
Lower Extremity ◽  
Disc Herniation ◽  
Epidural Injection ◽  
Low Back ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Lower Extremity Pain ◽  
Epidural Steroid ◽  
Caudal Epidural ◽  
Corticosteroid Injections

"Chronic low back and lower extremity pain is mainly caused by lumbar disc herniation (LDH) and radiculitis. Various surgery and nonsurgical modalities, including epidural injections, have been used to treat LDH or radiculitis. Caudal epidural injection of local anesthetics with or without steroids is one of the most commonly used interventions in managing chronic low back and lower extremity pain. To describe the indications, rationale, techniques, alternatives, contraindications, complications, and efficacy of lumbar and caudal epidural corticosteroid injections. Interventions: Three reviewers with formal training and certification in evidence-based medicine searched the literature on non–image guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. A systematic literature search was performed, in the Medline Case reports and retrospective and prospective studies were extensively reviewed to provide detailed descriptions of the clinical features of lumbar and caudal epidural corticosteroid injections. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE , and manual searches of bibliographies of known primary and review articles. Epidural corticosteroid injections are commonly requested treatments for patients with various low-back or lower-extremity pain syndromes (or both). Most of the reports on the use of this type of treatment are retrospective and noncontrolled. These studies indicate benefit; however, the prospective controlled studies provide varied results about the efficacy of lumbar and caudal epidural corticosteroid injections. In conclusions: In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available."

scholarly journals Comparative study between transforaminal epidural selective nerve root block versus interlaminar epidural in the treatment of lumbar radicular leg pain

2019 ◽  
Vol 5 (4) ◽  
pp. 694
Author(s):  
Mohammed Sadiq ◽  
Syed Azher Hussain ◽  
Mohammed Nayeemuddin
Keyword(s):  
Targeted Delivery ◽  
Nerve Root ◽  
Comparative Trial ◽  
Epidural Injection ◽  
Leg Pain ◽  
Disc Disease ◽  
Nerve Roots ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

<p class="abstract"><strong>Background:</strong> Sciatic neuralgia is a result of nerve root oedema because of the inflammatory, immunological and mechanical factors. Steroid injections play an important role in the management of sciatic radiculopathy. Steroids act by reducing the oedema around the nerve roots and decreasing pain. Locally administered steroids have the advantage of reduced dosage and targeted delivery around the nerve roots. This forms the basis of epidural steroid injections. This can be given around the nerve root in the transforaminal space or in the interlaminar space. There is a paucity of literature comparing the two techniques of epidural steroid injections. We have done a randomized comparative trial, to compare the effectiveness of the two modalities of injection in the management of a single level unilateral foraminal disc herniation.</p><p class="abstract"><strong>Methods:</strong> Patients were randomized in two groups Group A: Transforaminal epidural (SNRB) and Group B: interlaminar epidural. Same dose of steroid was used in each group.<strong></strong></p><p class="abstract"><strong>Results:</strong> Immediate post injection, 2 week and 1 month transforaminal epidural (SNRB) was better compare to interlaminar epidural however at the end of 3 months the difference was not significant (p=0.08).</p><p><strong>Conclusions:</strong> Both transforaminal and interlaminar epidural injection are effective form of treatment in mild to moderate grade of disc disease. Both the technique provide short lasting relief in the symptoms associated with disc pathology, however pain management is better in transforaminal group compared to interlaminar group. Thus these techniques can be considered for delaying surgery and providing intermitant relief. </p>

scholarly journals Neck movement during cervical transforaminal epidural injections and the position of the vertebral artery: an anatomical study

2019 ◽  
Vol 8 (3) ◽  
pp. 205846011983468
Author(s):  
Juan Altafulla ◽  
Emre Yilmaz ◽  
Stefan Lachkar ◽  
Joe Iwanaga ◽  
Jacob Peacock ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Guide Wire ◽  
Anatomical Study ◽  
Epidural Injection ◽  
Digital Subtraction ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Intervertebral Foramina ◽  
Digital Subtraction Fluoroscopy

Background Cervical transforaminal epidural steroid injections (CTFESIs) are sometimes performed in patients with cervical radiculopathy secondary to nerve-root compression. Neck movements for patient positioning may include rotation, flexion, and extension. As physicians performing such procedures do not move the neck for fear of injuring the vertebral artery, we performed fluoroscopy and cadaveric dissection to analyze any movement of the vertebral artery during head movement and its relation to the foramina in the setting of CTFESI. Purpose To determine cervical rotational positioning for optimized vertebral artery location in the setting of cervical transforaminal epidural steroid injections. Material and Methods Four sides from two Caucasian whole cadavers (all fresh-frozen) were used. Using a guide wire and digital subtraction fluoroscopy, we evaluated the vertebral artery mimicking a CTFESI, then we removed the transverse processes and evaluated the vertebral artery by direct observation. Results After performing such maneuvers, no displacement of the vertebral artery was seen throughout its course from the C6 to the C2 intervertebral foramina. To our knowledge, this is the first anatomical observation of its kind that evaluates the position of the vertebral artery inside the foramina during movement of the neck. Conclusion Special caution should be given to the medial border of the intervertebral foramina when adjusting the target site and needle penetration for the injection. This is especially true for C6-C4 levels, whereas for the remaining upper vertebrae, the attention should be focused on the anterior aspect of the foramen. Since our study was centered on the vertebral artery, we do not discard the need for contrast injection and real-time digital subtraction fluoroscopy while performing the transforaminal epidural injection in order to prevent other vascular injuries.

scholarly journals Comparison of Caudal Epidural Steroid Injection with Interlaminar Lumbar Epidural Injection in treating Spinal Stenosis

2021 ◽  
Vol 15 (9) ◽  
pp. 2168-2170
Author(s):  
Muhammad Akram ◽  
Faheem Mubashir Farooqi ◽  
Tauseef Ahmad Baluch ◽  
Shumaila Jabbar
Keyword(s):  
Spinal Stenosis ◽  
Steroid Injection ◽  
Epidural Injection ◽  
Epidural Steroid Injection ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Group I ◽  
Group Ii ◽  
Epidural Steroid ◽  
Caudal Epidural

Background: Lumbar spinal stenosis is a condition caused by narrowing of spinal canal. Steroid injection either lumbar or caudal can improve the functional outcome and low back pain. Aim: To compare the outcome of caudal epidural steroid injection with lumbar epidural steroid injection in treating spinal stenosis in patients suffering from sciatica. Methods: In this prospective study 338 patients having low backache due to spinal stenosis with sciatica were included from June 2013 to December 2014. Patients were randomly divided into two groups. Group I and II. Patients in Group I (160 patients) received caudal epidural steroid injections while the patients in Group II (178 patients) received lumbar epidural steroid injections. Visual analog scale (VAS) and Oswestry Disability Index (ODI) was used to assess outcome of the Caudal and Lumbar steroid injections and was measured at 2 weeks, at 3months, and improvement was declared if VAS decrease ≥50% of baseline and Oswestry disability index decrease ≥40% at 3 months. Results: In group I, there were 70(43.75%) males and 90(56.25%) females, while in group II there were 98(55.1%) males and 80(44.9%) females. The mean age of the patients in group I was 46.46±10.37 (18-75 years) years and was 43.77±15.27 years (18-75 years) in group II (P=0.0619). The change in pain score (>50%) was observed in 159 (89.33%) in group II compared with 121 (75%) in group I (P=0.0008). Conclusion: Lumbar epidural of steroids injections are more effective then caudal epidural injection of steroids in treating spinal stenosis. MeSH words: Caudal epidural, Lumbar epidural, Sciatica

The retroneural approach: an alternative technique for lumbar transforaminal epidural steroid injections

2018 ◽  
Vol 59 (12) ◽  
pp. 1508-1516
Author(s):  
Stefan Ignjatovic ◽  
Reza Omidi ◽  
Rahel A Kubik-Huch ◽  
Suzanne Anderson ◽  
Frank J Ahlhelm
Keyword(s):  
Pain Relief ◽  
Nerve Root ◽  
Spinal Cord Infarction ◽  
Short Term ◽  
Neural Foramen ◽  
Ct Guided ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Tip Position ◽  
Epidural Steroid

Background Compared with other available injection techniques for lumbar transforaminal epidural steroid injections (LTFESIs), the traditionally performed subpedicular approach is associated with a higher risk of spinal cord infarction, a rare but catastrophic complication. Purpose To assess the short-term efficacy of the retroneural approach for computed tomography (CT)-guided LTFESIs with respect to different needle-tip positions. Material and Methods This retrospective analysis included 238 patients receiving 286 CT-guided LTFESIs from January 2013 to January 2016. Short-term outcomes in terms of pain relief were assessed using the visual analogue scale (VAS) at baseline and 30 min after. The needle-tip location was categorized as extraforaminal, junctional, or foraminal relative to the neural foramen. Additionally, the distance from the needle tip to the nerve root was measured. Results A mean pain reduction of 3.22 points (±2.17 points) on the VAS was achieved. The needle-tip location was extraforaminal in 48% (136/286), junctional in 42% (120/286), and foraminal in 10% (28/286) of the cases. The mean distance from the needle tip to the nerve root was 3.83 mm (±3.37 mm). There was no significant correlation between pain relief and needle-tip position in relation to the neural foramen. Therapy success was not dependent on the distance between the needle tip and the nerve root. No major complications were observed. Conclusion In our population treated with LTFESIs, the retroneural approach was shown to be an effective technique, with no significant differences in pain relief following different needle-tip positions.

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