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Objectives The S1 dorsal foramen is the route for 30% of lumbar transforaminal epidural injections; it is therefore important to identify structures impeding S1 foraminal access. The study objective was to characterize the imaging findings, prevalence, and anatomic origin of synovial cysts presenting within the S1 neural foramen. Methods A case series (N = 14) established imaging characteristics of S1 synovial cysts. Imaging studies of 400 patients undergoing epidural injections were reviewed for lesions compromising S1 foraminal access. Cadaveric dissections defined the relationship of the inferior recess of the L5-S1 facet to the S1 dorsal foramen. Results Elderly patients (mean age = 76) exhibited S1 synovial cysts. Synovial cysts were typically 1–2 cm in diameter, hyperintense on sagittal T2 weighted magnetic resonance images (MRIs), fluid-density on computed tomography, and dorsal to the S1 spinal nerve. Sixty percent of cysts exhibited complex MRI signal characteristics (thick wall, internal structure). Tarlov cysts, in contrast, were larger, lobular, and exhibited pure fluid intensity. Lesions impeded access to the S1 dorsal foramina in 5% of reviewed imaging studies (16 Tarlov cysts, three synovial cysts, one conjoint S1-S2 nerve root). The multifidus muscle was interposed between the L5-S1 facet inferior recess and the S1 dorsal foramen on dissection specimens; severe atrophy of the ipsilateral multifidus was noted on imaging in 17/18 synovial cysts. Conclusions The S1 neural foramina should be inspected on sagittal MRI, when available, for confounding lesions before performing S1 epidural injections. Tarlov cysts are more common than synovial cysts; the latter are seen in elderly patients with severe multifidus atrophy. [ABSTRACT FROM AUTHOR]

Objective. To examine associations between imaging characteristics of compressive lesions and patient outcomes after lumbar transforaminal epidural steroid injections (TFESIs) stratified by steroid formulation (solution versus suspension). Design/Subjects. Retrospective observational study, academic radiology practice. A 516-patient sample was selected from 2,634 consecutive patients receiving lumbar TFESI for radicular pain. Methods. The advanced imaging study(s) preceding sampled TFESI were reviewed. Compressive lesions were described by a) nature of the lesion [disc herniation, fixed stenosis, synovial cyst, epidural fibrosis, no lesion] b) degree of neural compression [4 part scale], and c) presence of a tandem lesion. Associations between 2-month categorical outcomes (responder rates for pain, functional recovery) and imaging characteristics, stratified by steroid formulation, were examined with chi-squared tests of categorical outcomes and multivariable logistic regression models. Results. Disc herniation patients had more responders for functional recovery than patients with fixed lesions (54% versus 38%, P=0.01). Patients with fixed lesions receiving steroid solution (dexamethasone) had more responders for pain relief, with a similar trend for functional recovery, than patients receiving suspensions (59% versus 40%, P5=0.01). Outcomes for patients with fixed lesions treated with dexamethasone were not statistically different from those for disc herniation patients. Patients with single compressive lesions had more responders than those with tandem lesions (55% versus 41%, P=0.03). Conclusion. In the entire sample, outcomes for disc herniations were more favorable than for fixed lesions. However, fixed lesions treated with dexamethasone had outcomes indistinguishable from disc herniations. Single lesions had better outcomes than tandem lesions. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study was to determine 1) if repeat lumbar transforaminal epidural steroid injections (TFESIs) resulted in recovery of pain relief, which has waned since an index injection, and 2) if cumulative benefit could be achieved by repeat injections within 3 months of the index injection. Design. Retrospective observational study with statistical modeling of the response to repeat TFESI. Setting. Academic radiology practice. Patients. Two thousand eighty-seven single-level TFESIs were performed for radicular pain on 933 subjects. Subjects received repeat TFESIs >2 weeks and <1 year from the index injection. Methods. Hierarchical linear modeling was performed to evaluate changes in continuous and categorical pain relief outcomes after repeat TFESI. Subgroup analyses were performed on patients with <3 months duration of pain (acute pain), patients receiving repeat injections within 3 months (clustered injections), and in patients with both acute pain and clustered injections. Results. Repeat TFESIs achieved pain relief in both continuous and categorical outcomes. Relative to the index injection, there was a minimal but statistically significant decrease in pain relief in modeled continuous outcome measures with subsequent injections. Acute pain patients recovered all prior benefit with a statistically significant cumulative benefit. Patients receiving clustered injections achieved statistically significant cumulative benefit, of greater magnitude in acute pain patients. Conclusion. Repeat TFESI may be performed for recurrence of radicular pain with the expectation of recovery of most or all previously achieved benefit; acute pain patients will likely recover all prior benefit. Repeat TFESIs within 3 months of the index injection can provide cumulative benefit. [ABSTRACT FROM AUTHOR]

Objective To assess whether computed tomography( CT)-guided injections of local anesthetic and corticosteroid into chronic lumbar pars interarticularis defects may identify and provide benefit to a cohort of patients where the pars defects act as a primary axial pain generator. Design Retrospective practice audit. Setting Single academic radiology pain management practice. Patients 59 consecutive patients undergoing CT-guided injections of lumbar pars defects. Methods Patients were assessed with a pain numerical rating scale ( NRS, 0-10) and Roland- Morris disability questionnaire ( R- M) prior to injection and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief response was defined as either ≥50% reduction in NRS or pain 0/10; functional response was defined as ≥40% reduction in R- M score. Continuous outcomes (mean NRS, R- M scores) were assessed for significant change following injection. Results For categorical outcomes, 37.9% of patients were responders at 2 months' follow-up; 20.7 % had complete relief of index pain. For functional recovery, 34.5% were responders at 2 months. Using continuous outcomes, mean NRS was 5.4 ± 2.1 prior to injection and 3.6 ± 2.6 at 2 months ( P < 0.0001). Mean R- M score was 11.7 ± 6.0 prior to injection and 9.0 ± 5.4 at 2 months ( P = 0.001). There were no complications. Conclusions This practice audit suggests that in patients with axial low back pain and chronic pars defects, the pars defects may be implicated as the primary axial pain generator in a small subgroup of patients. Local deposition of corticosteroids into the pars defect may provide significant pain relief in one out of three patients, and complete relief in one out of five patients. This data suggest there may be benefit to pursuing randomized controlled trials of pars injections comparing steroid injection with placebo. [ABSTRACT FROM AUTHOR]

Objective To assess whether a nonparticulate steroid (dexamethasone, 10 mg) is less clinically effective than the particulate steroids (triamcinolone, 80 mg; betamethasone, 12 mg) in lumbar transforaminal epidural steroid injections ( TFESIs) in subjects with radicular pain with or without radiculopathy. Design Retrospective observational study with noninferiority analysis of dexamethasone relative to particulate steroids. Setting Single academic radiology pain management practice. Subjects Three thousand six hundred forty-five lumbar TFESIs at the L4-5, L5- S1, or S1 neural foramina, performed on 2,634 subjects. Methods/Outcome Measures Subjects were assessed with a pain numerical rating scale ( NRS, 0-10) and Roland- Morris disability questionnaire ( R- M) prior to TFESI, and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R- M score. Noninferiority analysis was performed with δ = −10% as the limit of noninferiority. Continuous outcomes (mean NRS, R- M scores) were analyzed for noninferiority with difference bounds of 0.3 for NRS scores and 1.0 for R- M scores. Results With categorical outcomes, dexamethasone was demonstrated to be noninferior to the particulate steroids in pain relief and functional improvement at 2 months. Using continuous outcomes, dexamethasone was demonstrated to be superior to the particulate steroids in both pain relief and functional improvement at 2 months. Conclusion This retrospective observational study reveals no evidence that dexamethasone is less effective than particulate steroids in lumbar TFESIs performed for radicular pain with or without radiculopathy. [ABSTRACT FROM AUTHOR]

Objectives. To assess the clinical effectiveness of single lumbar transforaminal epidural steroid injections ( TFESIs) in subjects with radicular pain with or without radiculopathy. Design. Retrospective observational series. Setting. Single academic radiology pain management practice. Subjects. Two thousand twenty-four subjects undergoing single lumbar TFESIs at the L4-5, L5- S1, or S1 neural foramina. Methods / Outcome Measures. Subjects were assessed with a pain numerical rating scale ( NRS, 0-10) and Roland-Morris disability questionnaire ( R-M, 23-point Deyo modification) prior to TFESI and at 2 weeks and 2 months follow-up. Successful pain relief (responders) was defined as either ≥50% reduction in NRS or pain 0/10; functional success was defined as ≥40% reduction in R-M score. Results. There were statistically significant ( P < 0.0001) reductions in mean NRS and R-M scores at 2 weeks and 2 months postinjection. For NRS, 40.9% were responders at 2 weeks and 45.6% at 2 months. For R-M, 31.9% were responders at 2 weeks and 41.3% at 2 months. The proportion of responders for NRS and R-M was higher when there was <3 months of pain (odds ratio 2-month NRS = 2.42 [95% confidence interval: 1.82, 3.24], odds ratio 2-month R-M = 2.61 [1.96, 3.48]). For subjects with <3 months of pain, the proportion of responders was 62.4% (56.5, 68.3%) for NRS and 59.3% (53.3, 65.3%) for R-M scores. Conclusions. This retrospective observational study suggests TFESIs are clinically effective in the treatment of lumbar radicular pain. Subjects with a shorter duration of pain are more likely to achieve a successful outcome. [ABSTRACT FROM AUTHOR]

Objective To assess frequency of sedation in transforaminal epidural steroid injections ( TFESI) and to analyze patient dissatisfaction and vasovagal rates. Design Retrospective audit over a 6-year period, January 1, 2006-December 31, 2011. Setting Single academic center radiology pain management practice. Subjects Four thousand four hundred thirty-two patients undergoing 6,878 consecutive TFESI. Outcome Measures Frequency of sedation for TFESI was assessed. Vasovagal and patient dissatisfaction rates were assessed, the latter by patients' responses to two follow-up survey questions at 2 weeks postprocedure. Results Six thousand eight hundred seventy-eight TFESI were performed, of which only 0.1% (N = 7) were performed with sedation. Only 0.4% (N = 28) of TFESI were complicated by vasovagal reaction. Seventy-two percent (N = 4,980) of nonsedated patients responded to the survey. Overall medical care in the nonsedated was rated as: excellent 51%, very good 30%, good 15%, fair 3%, and poor 1%. Ninety-five percent confidence interval ( CI) for the 3.9% of the nonsedated patients who rated their care at best 'fair' was (3.3, 4.4%). Likelihood of referring friends/family members in nonsedated patients was: definitely 53%, probably 28%, uncertain 16%, probably not 3%, definitely not 0.2%. Ninety-five percent CI for the 3.2% of the nonsedated patients who would at best 'probably not refer' their friends/family was (2.7, 3.7%). Conclusions In our radiology pain management practice, sedation was rarely utilized for TFESI. A small minority of nonsedated patients rated their care at best fair and would at best probably not refer friends/family members. TFESI can be performed without sedation with low patient dissatisfaction and low vasovagal rates. [ABSTRACT FROM AUTHOR]