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Background and Objectives : This study aimed to evaluate the mid-term effectiveness and safety of a combined ultrasound (US) and fluoroscopy (FL)-guided approach in comparison to US-guided and FL-guided caudal epidural steroid injections (CESI) for treating unilateral lower lumbar radicular pain. Materials and Methods : A total of 154 patients who underwent CESI between 2018 and 2022 were included. Patients were categorized into three groups based on the guidance method: combined US and FL (n = 51), US-guided (n = 51), and FL-guided (n = 52). The study design was retrospective case-controlled, utilizing patient charts and standardized forms to assess clinical outcomes, adverse events, complications during the procedures. Results : In all groups, Oswestry Disability Index and Verbal Numeric Scale scores improved at 1, 3, and 6 months after the last injection, with no significant differences between groups ( p < 0.05). The treatment success rate at all time points was also similar among the groups. Logistic regression analysis showed that injection method, cause, sex, age, number of injections, and pain duration did not independently predict treatment success. Blood was aspirated before injection in 2% (n = 1), 13.5% (n = 7), and 4% (n = 2) of patients in the combined US and FL groups, FL-guided groups, and US-guided groups, respectively. Intravascular contrast spread was detected in one patient in the combined method groups and seven in the FL-guided groups. Conclusions : When comparing pain reduction and functional improvement, there was no significant difference between the three methods. The combined method took less time compared to using FL alone. The combined approach also showed a lower occurrence of intravascular injection compared to using FL alone. Moreover, blood vessels at the injection site can be identified with an ultrasound using the combined method. Given these advantages, it might be advisable to prioritize the combined US- and FL-guided therapy when administering CESI for patients with unilateral lumbar radicular pain.

Background: Low back pain (LBP) and lumbosacral radiculopathy are frequent disorders that cause nerve root injury, resulting in a variety of symptoms ranging from loss of sensation to loss of motor function depending on the degree of nerve compression., Objectives: The goal of this study was to investigate the effectiveness of various epidural injection procedures in adult LBP patients., Study Design: Systematic review and network meta-analysis., Setting: Egypt., Methods: PubMed, Scopus, Web of Science, Cochrane Database, and Embase were used to conduct an electronic literature search. We included RCTs, cohorts, case controls, patients 30 years old with a clinical presentation of low back pain, and comprehensive data on the effects of the intervention on patients with lumbosacral radicular pain who got epidural steroid injections via various techniques. Only papers written in English were eligible., Results: Our analysis showed that parasagittal intralaminar (PIL) was the most effective approach in decreasing VAS (0-10) in the short term (< 6 months) (MD = -1.16 [95% CI -2.04, -0.28]). The next significant approach was transforaminal (TF) (MD = -0.37 [95% CI -1.14, -0.32]) in the long term; TF was the most effective approach (MD = -0.56 [95% CI -1, -0.13]). According to VAS (0-100) in the short term (< 6 months), our analysis showed an insignificant difference among the injection approaches and in the long term; TF was the most effective approach (MD = -24.20 [95% CI -43.80, -4.60]) and the next significant approach was PIL (MD = -23.89 [95% CI -45.78, -1.99])., Limitations: The main limitations are the heterogeneity encountered in some of our analyses in addition to studies assessed as high risk of bias in some domains., Conclusion: TF was the most effective steroid injection approach. In decreasing VAS for short-term PIL and TF were the most significant approaches, but TF was the most effective approach in decreasing VAS for the long term. Also, TF was the most effective approach in decreasing ODI for the long term., (© 2023 World Institute of Pain.)

Aim: To investigate the demographic, clinical and radiological findings associated with treatment success after interlaminar epidural steroid injection (ILESI) in radicular pain induced by cervical disc herniation., Material and Methods: In this retrospective study, the data of patients who received cervical ILESI between January 2017 and June 2021 were screened. Of 223 patients, 92 with unilateral radicular neck pain due to cervical disc herniation were included. Demographic data, symptom duration, and numerical rating scale scores at baseline, at three weeks, three months, and six months after treatment were collected from the medical records of the patients. Disc herniation level, cervical axis, disc height, presence and degree of spinal canal and neural foraminal stenosis, vertebral endplate signal change, and definitive presence of uncovertebral and facet osteoarthritis were evaluated using cervical spine magnetic resonance imaging. Treatment success was determined as ?50% reduction in pain scores at six months compared to baseline., Results: Data of 92 patients (27 men, 65 women) were included. The mean age was 50.82 ± 10.22 years, and the median symptom duration was 12 (4.25 to 20) months. At six months after ILESI, treatment was successful in 58 (58.7%) patients and unsuccessful in 34 (41.3%) patients. Multivariable logistic regression analysis was performed to identify the factors associated with treatment success at six months post-injection. In the final model, neural foraminal stenosis (non-severe vs. severe) and spinal canal stenosis (non-severe vs. severe) were significantly associated with the treatment success (OR=3.02, 95% CI=1.40?10.95, p=0.009; OR=5.31, 95% CI=1.77?15.85, p=0.003)., Conclusion: Treatment success of cervical ILESI at six months is favorable. However, the presence of severe neural foraminal and spinal canal stenosis is associated with a reduced likelihood of treatment success.

Background: Spinal malignancy-related pain results from tumor, fracture, instability, inflammation, and/or nerve root/spinal cord compression. Systemic corticosteroids are commonly used but have many undesirable adverse effects that impact quality of life and continuation of cancer treatments. Epidural steroid injections (ESIs) may be a viable alternative pain treatment., Objectives: This study starts with a pragmatic review on the efficacy of ESIs to treat spinal malignancy-related pain. Given the limited evidence, we supplement the study with a single-center, retrospective review., Methods: A pragmatic review using PRISMA guidelines was conducted in MEDLINE, EMBASE, SCOPUS, and Cochrane Review. Then, a retrospective chart review was performed., Results: A pragmatic review yielded 10 patients who underwent ESI for spinal malignancy-related pain. Three patients had "excellent" relief (≥ 50% relief), who all received thoracic injections. This amounted to level IV evidence and an inconclusive recommendation (Grade C) as per Wright's criteria. In our retrospective review, all thoracic cases achieved at least "moderate" pain improvement (30% to 49% relief). 55.6% had "excellent" relief. Lumbosacral injections resulted in 86.0% with at least "moderate" relief and 69.8% with "excellent" relief. Caudal injections were less likely to benefit than lumbosacral injections (P = 0.02). The transforaminal approach resulted in the best relief. There were no adverse events., Conclusions: There is inconclusive evidence to use ESIs to treat spinal malignancy-related pain in the current literature. Our retrospective review provides level III evidence for our conclusion that ESIs are safe and efficacious to treat spinal malignancy-related pain. Thoracic/lumbosacral injections led to significantly better pain relief compared with caudal injections., (© 2020 World Institute of Pain.)

Background: Cervical epidural steroid injections (ESI) are performed either by interlaminar (IL) or transforaminal (TF) approaches; however, there is controversy over which is better for safety and efficacy., Objectives: This clinical trial aimed to compare the effectiveness of the parasagittal IL and TF approaches for cervical ESI in patients who were suffering from cervical radicular pain., Study Design: A prospective randomized assessor-blind study., Setting: The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea., Methods: This prospective randomized, assessor-blind trial included 80 patients with cervical radicular pain. We randomly assigned patients to the TF or parasagittal IL approach for cervical ESI. The effectiveness of the 2 groups was compared based on pain intensity using the Numeric Rating Scale (NRS-11) at 1 and 3 months. The Neck Disability Index (NDI), Medication Quantification Scale (MQS), and responders at 1 and 3 months between the 2 groups were compared., Results: The pain intensity of both groups significantly reduced after 1 and 3 months after each procedure (P < 0.001). Two-way repeated measures of analysis of variance showed no significant interaction between group and time for cervical radicular pain (P = 0.266), although NRS-11 pain score was lower in the TF group than the parasagittal IL group after 1 month (P = 0.010). NDI, MQS, and successful responders were not different between the 2 groups at 1 and 3 months after the procedure. We observed 7 cases (18.4%) of vascular visualization in the TF group, although no serious complications were found in either group., Limitations: This study had no placebo control group and limited follow-up time., Conclusions: Parasagittal IL ESI may be recommended over the TF ESI in reducing cervical radicular pain, considering both clinical effectiveness and safety.

Background: Chronic neck pain is reportedly considered the fourth leading cause of disability. Cervical interlaminar epidural injections are among the commonly administered nonsurgical interventions for managing chronic neck pain, secondary to disc herniation and radiculitis, spinal stenosis, or chronic neck pain of discogenic origin., Objectives: To systematically review the differences in the effectiveness of cervical epidural injections with local anesthetics with or without steroids for the management of chronic neck pain., Study Design: Systematic review and meta-analysis., Methods: A comprehensive search of the literature of randomized controlled trials (RCTs) that compared epidural injections with local anesthetic with or without steroids was performed, including a search of PubMed, EMBASE, and Cochrane databases for all years up to May 2019. Meta-analysis was done for pain relief based on the Numeric Rating Scale, functional status based on the Neck Disability Index, and opioid intake dosage., Results: Four studies met the inclusion criteria. A total of 370 patients were divided into 2 groups: the experimental group received cervical epidural injection with steroid and local anesthetic, and the control group received injection with local anesthetic only. Regrading pain relief, no significant difference was observed between both groups (weighted mean difference [WMD], -0.006; 95% confidence interval (CI), -0.275 to 0.263; P = 0.963; I² = 0.0% at 12 months). There was also no significant difference in the improvement of the functional status (WMD, 0.159; 95% CI, -1.231 to 1.549; P = 0.823; I² = 9.8% at 12 months). Similarly, there was no significant difference in opioid dosage (WMD, -0.093; 95% CI, -5.952 to 5.766; P = 0.975; I² = 0.0% at 12 months)., Limitations: Only a few studies on this premise were found in the literature. There was also a lack of heterogeneity of the included RCT studies., Conclusions: The addition of steroids to anesthetic injectates was not associated with better pain and functional score outcomes compared with anesthetic injectate alone in patients with chronic neck pain., Key Words: Chronic neck pain, cervical radiculopathy, cervical disc disease, spinal stenosis, facet joint pathology, cervical epidural injections, steroid injections, local anesthetic injections, systematic review, meta-analysis, randomized control trial.

Aims: This study aims to investigate the effectiveness of transforaminal epidural steroid injection (TFESI) in patients with lumbar radicular pain or radiculopathy caused by different spinal pathologies., Methods: One hundred and seventy seven patients who underwent single transforaminal epidural steroid injection were included in the study group and divided into 3 subgroups (central spinal stenosis + lateral recess stenosis, foraminal stenosis, lumbar disc herniation) according to existing spinal pathology. Patients' visuel analogue scale (VAS) measures and Oswestry Disability Index (ODI) scores were recorded and the patients who give favourable response to treatment were called respondents and who were not called as non-respondents. Subgroups were compared statistically at the end of 12 months., Results: Sixty patients (33.9%) were considered as respondents and 117 patients (66.1%) were non-respondents in the entire study group. Patients with foraminal stenosis included the vast majority of the respondents and showed better results of pain relief as opposed to patients of other groups at the end of 12 months (P < 0.001)., Conclusion: TFESI was an effective treatment modality for pain relief and functional improvement in patients with foraminal stenosis. However, it could not produce the same results in patients with central spinal stenosis and lumbar disc herniations., Competing Interests: None

Aim: The aim of this case report is to describe ultrasound guidance for caudal epidural steroid injection during pregnancy. Case report: A 29-year-old, 32-week parturient presented with severe back and leg pain with MRI demonstrating herniation of the L5-S1 level. The disabling pain was refractory to conservative therapy, and an ultrasound-guided caudal epidural steroid injection was performed. There was significant pain relief in the first week with an uneventful subsequent pregnancy. Following delivery, the patient had no further recurrence of her presenting symptoms. Conclusion: Severe radiculopathy may be encountered during pregnancy, complicated by a limited number of treatment options. Ultrasound guidance should be considered during performance of caudal epidural injections in feasible cases.

Background: Epidural steroid injections (ESIs) are commonly used for management of lumbosacral radicular pain. Midline interlaminar (MIL) or transforaminal (TF) routes are commonly used. The TF route, although associated with higher delivery of drug to the ventral epidural space, has serious complications including spinal cord injury and permanent paralysis reported in literature. Therefore, there is a search for a technically better route with fewer complications and greater drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach has been defined., Objectives: We conducted this study to compare therapeutic effectiveness of 3 techniques of ESIs in patients having unilateral lumbar radiculopathy. Further, effect of ESI on bone mineral density (BMD) and serum osteocalcin levels were studied., Study Design: Randomized double-blind trial., Setting: Pain clinic of a tertiary care hospital., Methods: Sixty-five patients were randomly allocated into group MIL, group PIL, and group TF to receive epidural injection with 80 mg of methylprednisolone and 2 mL of 2% lidocaine. Effective pain relief and improvement in disability were assessed using Visual Analog Scale (VAS) and Modified Oswestry Disability Questionnaire (MODQ) scores at 2 weeks, 4 weeks, 3 months, and 6 months, respectively. Patients with < 50% relief received additional injection. Primary outcome of study was effective pain relief at 6 months. Mean change in VAS and MODQ scores, BMD, and serum osteocalcin levels were secondary outcome assessed., Results: Patients having effective pain relief were significantly higher in group PIL (16 of 20 [80%]) and group TF (15 of 20 [75%]) compared with group MIL. Patients receiving ESI in group PIL and group TF showed significantly lower VAS scores than group MIL (P = 0.02, P = 0.50 at 3 months and P = 0.00, P = 0.02 at 6 months, respectively). Mean MODQ scores in group PIL and group TF were significantly lower than group MIL. However, group PIL and group TF did not significantly differ in MODQ scores. There was no significant change in serum osteocalcin and BMD, as assessed by dual energy x-ray absorptiometry scan at 3 months., Limitations: The absence of a placebo control group, small sample size, and relatively short follow-up of 6 months were limitations., Conclusions: PIL approach is equivalent to TF and superior to MIL approach in terms of effective pain relief and decrease in disability in patients with unilateral lumbar radiculopathy. This study showed no deleterious effect on BMD., Key Words: Epidural steroid, technique, efficacy, bone marrow density, serum osteocalcin.

Background: Selective Nerve Root Block using steroid is a proven technique for management of lumbar radiculopathy. The aim of the study was to determine the effectiveness of selective nerve root block in lumbar radiculopathy., Methods: A prospective observational study was conducted for duration of one year in patients diagnosed with lumbar radiculopathy. Patients with leg pain, positive straight leg raising test and single level disc prolapse were included in the study. The procedure was performed under fluoroscopic guidance and Visual Analogue Pain rating scale and Oswestry Disability Index score was used for assessment pre-injection, 1 week, 1 month, 6 months and 1-year post injection., Results: Total 35 patient with mean age of 37.7± 9.31 years were included in the study. The pre-injection Visual Analogue Pain Score(Mean ± S.D:7.8±0.7) was significantly reduced at one week (4.2±1.47, p <0.00001), one month (2.74±1.06, p <0.00001), six months (2.31±0.75, p <0.00001) and one year (2.62±0.84, p <0.00001). Similarly, pre-injection Oswestry Disability Index score (Mean ± S.D: 32.09±5.95) was significantly reduced at one week (19.51±7.26, p <0.00001), one month (12.71±4.56, p <0.00001), six months (9.8±2.87, p <0.00001) and one year (10.09±2.97, p <0.00001) but not significantly improved when compared at 6 months and 1 year (p < 0.44)., Conclusions: Selective Nerve Root Block in lumbar radiculopathy significantly reduces Visual Analogue Pain Score up to a year, however, the reduction in pain plateaus around six months.Disability index score only reduces for first 6 months but doesn't significantly reduce from six months to one year.

Objective: To examine the impact of the presence of facet tropism on the results of transforaminal epidural steroid injection for unilateral radicular pain induced by lumbar disc herniation., Materials and Methods: We included 112 patients diagnosed with unilateral, single-level lumbar disc herniation-induced radicular pain. Injection was planned at relevant levels. The patients were assessed using the Numerical Rating Scale, the Modified Oswestry Disability Index, and the Beck Depression Inventory before the injection and at hour 1, week 3, and month 3 after the injection. Presence of facet tropism was assessed by measuring the facet angles in the L3-4, L4-5, and L5-S1 segments of lumbar MRI T2 sequence axial section., Results: A significant decrease in the Numerical Rating Scale and an increase in the Modified Oswestry Disability Index scores were detected at all follow-ups in groups comprising 39 patients with and 61 without facet tropism (p < 0.05). On comparison, improvement in clinical parameters at week 3 and month 3 in the group without facet tropism was greater (p < 0.05). As treatment success is considered to be a ≥ 50% reduction in the Numerical Rating Scale scores, 55.2% of the patients attained treatment success at month 3. Further, although the treatment success rate in the group with facet tropism was 34.2%, it was 69% in that without facet tropism (p < 0.05)., Conclusion: Facet tropism correlates with less success of transforaminal epidural steroid injection; therefore, facet tropism may be a worthwhile measurement in a discussion with patients of the benefits of the procedure.

The approach we suggest was developed for cases in which the fourth and fifth lumbar and first sacral spinal nerves were affected in lumbar degenerative disc disease. Retrodiscal transforaminal epidural injection is known to be very effective for lumbar radiculopathy because of excellent access to primary pathology; however, access below L5 is often restricted by the anatomic characteristics of the L5-S1. In the translateral recess approach (TLR), proper final needle placement (i.e., in the axillary portion between the exiting and traversing nerve roots) can be achieved by setting the direction of the needle laterally and superiorly from the distal tip of the infra-adjacent spinous process toward the medial wall of the pedicle and neural foramen of the given level without neural injury. This approach is possible because of the wide interlaminar space in the L5-S1. Preganglionic epidural injection through TLR is an effective and safe spinal intervention for lumbosacral radiculopathy., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

Introduction: The treatment of persistent cervical radicular pain (CRP) by CT-guided epidural steroid injections (CTESI) by a transforaminal anterolateral (TFA) approach is associated with rare but serious complications. Two recently described transforaminal posterolateral (TFP) and transfacet indirect (TFT) approaches may be safer options, but have not been extensively evaluated. We compared the efficacy of three CTESI approaches (TFA, TFP, and TFT) in the treatment of persistent CRP (>6 weeks)., Methods: Patients were prospectively assessed for pain using the visual analog scale (VAS) and for functional disability by the Neck Disability Index (NDI) before treatment, then 6 weeks and 6 months after CTESI., Results: A total of 104 patients were included (n = 30 TFA, n = 36 TFP, and n = 38 TFT approaches). Each group was found to have a statistically significant improvement at 6 weeks (median VAS values: 7 (2-9) at D0 and 2 (3-6) at 6 weeks p < 0.01; median NDI values: 38 (24-50) at D0 and 29 (18-42) at 6 weeks (p < 0.01)), and at 6 months (median VAS values: 7 (2-9) at D0 and 4 (2-6) at 6 months (p < 0.01); median NDI values: 38 (24-50) at D0 and 28 (13-40) at 6 months (p < 0.01)). No significant difference was observed in the decrease in VAS and NDI scores among the three approaches at 6 weeks (p = 0.635 and p = 0.54 for VAS and NDI respectively) or 6 months (p = 0.704 and p = 0.315 for VAS and NDI respectively). No major complications were noted., Conclusion: The results of CTESI using the TFP or TFT approach are similar to those for TFA in the treatment of persistent CRP and could be a safer option.

Background: Epidural injection is performed for treatment of back and radicular pain in patients with lumbosacral disc herniation (LDH). Steroids are usually administered to effectively remove inflammatory mediators, and local anesthetics or saline also contribute to pain reduction by washing out chemical mediators or blocking the nociceptor activity. Controversy exists regarding whether steroids produce superior clinical effects compared with local anesthetics or saline., Objectives: This study investigated whether epidural injection of steroids produces better clinical effects than local anesthetics or saline in the treatment of LDH., Study Design: A literature search was performed in MEDLINE, EMBASE, Cochrane review, and KoreaMed for studies published from January 1996 until July 2017. From among the studies fulfilling the search criteria, those 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, non-specific low back pain, severe spinal stenosis, and severe disc degeneration., Setting: A systematic review and meta-analysis using a random effects model on randomized controlled studies (RCTs)., Methods: After reviewing titles, abstracts, and full texts of 6,711 studies that were chosen following removal of duplicates after the initial database search, 15 randomized controlled studies were included in our qualitative synthesis. Data including pain score, functional score, and follow-up period were extracted from 14 studies and analyzed using a random effects model to calculate the effect size and its corresponding statistical significance. Quality and level of evidence were established in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology., Results: Steroids and local anesthetics were shown to be effective. Steroid showed significantly better pain control than control agents at 1 month, 3 months, and 6 months. The superiority of steroid in pain control was more prominent at one month, but diminished from 3 months to 1 year, showing no significant superiority in terms of mean difference, With respect to functional score, no significant difference was observed between steroids and control agents. The subgroup analysis showed that steroid revealed significant superiority in pain and functional score at 1 month to saline rather than local anesthetics. Generally, the quality of included studies was evaluated as high-grade, but the evidence level was determined to be moderate, due to inconsistencies., Limitation: Analyses of safety or adverse effects could not be performed due to a lack of available data from the included studies., Conclusions: Steroid is recommended over local anesthetics or saline for pain control in patients with LDH, with a weak strength of recommendation. The superiority of steroids was remarkable, especially at relatively short-term follow-ups, and maintained until the 1 year follow-up. The clinical benefits of steroids at 1 month were more prominent when compared with saline, than when compared with local anesthetics., Key Words: Steroid, local anesthetics, saline, epidural injection, pain, function, meta-analysis, systemic review.

Rationale: Perineural cysts, commonly referred to as Tarlov cysts, are cerebrospinal fluid-filled dilations between the perineurium and endoneurium typically arising at the junction of posterior and dorsal root ganglia in the neural foramina. This anatomical location is in close proximity to usual needle trajectory during performing transforaminal epidural injection, and therefore presents a potential risk of dural puncture and associated complications., Patient Concerns: Severe lower extremity pain interfering with activities of daily living., Diagnoses: Lumbar radiculopathy secondary to left-sided L4-5 disc herniation in the presence of multilevel Tarlov cysts in the neural foramina., Interventions: Posterior interlaminar epidural steroid injection technique was preferred, as opposed to transforaminal approach, to avoid potential risk of dural puncture and associated complications in the presence of multilevel Tarlov cysts in the neural foramina., Outcomes: The patient responded favorably to epidural steroid injection via interlaminar approach with complete resolution of pain, symptoms, and signs. There were no complications. The patient was able to tolerate physical therapy, wean pain medications, and achieve normal activities of daily living without any significant limitations., Lessons: In patients presenting with an MRI report of "Tarlov cysts", meticulous evaluation of diagnostic images should be an essential first step before considering invasive spinal procedures. Should there be any presence of Tarlov cyst in close proximity to planned needle trajectory, we recommend appropriate modification of spinal intervention to avoid potential complications.

Objective: To investigate the relationship between epidurographic contrast dispersal patterns and both immediate and short-term clinical effectiveness of lumbar transforaminal epidural steroid injections (TFESIs) in patients with radicular back pain., Methods: A digital database of 64 patients who underwent single-level lumbar TFESI for unilateral lumbar radicular pain was scanned. The type of contrast pattern was analyzed by 1 physiatrist and defined as follows: type 1 (tubular appearance), type 2 (nerve root visible as a filling defect), or type 3 (cloud-like appearance). Pain was evaluated with a visual analog scale (VAS) and recorded before injection and 2 days, 2 weeks, and 3 months after injection., Results: The mean age was 45.9 ± 13.5 years (range, 22-80 years), and the mean duration of symptoms was 5.7 ± 4.2 months. Contrast distribution patterns were as follows: type 1 in 33 patients (51.6%), type 2 in 18 patients (28.1%), and type 3 in 13 patients (20.3%). Mean decrease in VAS scores at all time points was statistically significant in 3 types of contrast dispersal patterns (P < 0.05). Differences in improvements of VAS scores obtained at any assessment period and success rates were not statistically significant between groups. However, the ratio of patients who achieved 50% or greater reduction in pain scores was higher in type 1 and type 2 than type 3 at each follow-up point., Conclusions: TFSEIs have a beneficial effect in managing lumbar radicular pain regardless of contrast pattern type. Success rates were higher in type 1 and type 2 than type 3., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The predictive value of short-term arm pain relief after 'indirect' cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well., Methods: Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after 'indirect' ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as 'non-response'., Results: At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8-11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term., Conclusions: Patients who require a second injection or surgery after 'indirect' cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome.

Cervical epidural steroid injections are a common treatment of cervical radicular pain. Important safety considerations include attention to the possibility of spinal cord infarction and spinal epidural hematoma. When appropriate, radiographic, technical, and pharmacologic principals are used, these procedures are relatively safe. Cervical epidural steroid injections are effective for the short-term treatment of radicular pain. More rigorously designed clinical outcomes studies of both cervical interlaminar and transforaminal epidural steroid injections are needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Cervical transforaminal epidural steroid injection (TFESI) is considered one of the most effective treatments for radicular pain induced by cervical foraminal stenosis., Purpose and Design: We sought to evaluate the treatment outcome of TFESI according to the severity of cervical foraminal stenosis. In our retrospective study there were 53 patients with cervical radiculopathy due to cervical foraminal stenosis., Outcome Measures: Pain intensity was evaluated using a numeric rating scale (NRS) at pretreatment, 2 weeks, and 1, 2, and 3 months after TFESI., Methods: Patients were divided into 2 groups according to the severity of stenosis by cervical axial magnetic resonance imaging findings. Twenty-two patients were assigned to group A (nonsevere stenosis), and 31 patients were assigned to group B (severe stenosis)., Results: Thirty-seven (69.8%) of 53 patients showed successful treatment outcome (>50% reduction in the NRS score at 3 months). The patients in both groups showed a significant decrease in NRS scores at 2 weeks and at 1, 2, and 3 months after TFESI. However, the effect of TFESI was not significantly different between patients with nonsevere cervical foraminal stenosis and those with severe cervical foraminal stenosis., Conclusions: The treatment outcome of cervical TFESI did not different according to the severity of cervical foraminal stenosis. However, on the basis of our results, we suggest that TFESI can be a beneficial clinical option for managing radicular pain due to cervical foraminal stenosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To analyse the incidence and type of epidural steroid injection (ESI)-related adverse events, including procedure-related complications and drug-related systemic effects requiring hospitalisation or emergency room (ER) visits., Methods: This study included 52,935 ESI procedures performed in 22,059 patients in our department from March 2004 to February 2016. Of these, we retrospectively reviewed the cases of 1570 patients (1713 procedures) who were hospitalised or visited the ER within 1 month after ESI. ESI-related events were classified as procedure-related complications, drug-related systemic effects, or of uncertain relationship. Descriptive data are provided; no statistical analysis was performed., Results: There were 244 ESI-related events in 235 patients (males:females = 102:133; mean age: 65.7 years; range: 20-93 years). The incidence of ESI-related events was 0.46% per procedure, including 14 procedure-related complications, 56 drug-related systemic effects, and 174 events of uncertain cause. Of the 52,935 patients, 6 (0.011%) experienced major complications (two spine haematomas and four infections), 1 patient died, and 1 experienced neurological sequelae., Conclusions: Although major procedure-related complications and drug-related systemic effects of ESI requiring hospitalisation are very rare, infection and haematoma can occur, resulting in serious outcomes. Hence, ESI should be carefully considered in high-risk patients., Key Points: • The incidence of ESI-related events requiring hospitalisation was 0.46%. • The incidence of procedure-related complications was 0.026%. • The incidence of drug-related systemic effects was 0.11%. • The incidence of major complication of ESI was 0.011%. • The major complications were spine infection, haematoma, and sepsis.

Background: Epidural steroid injection is widely used to treat the short and long-term symptoms of low back and radicular pain. To the best of our knowledge, the influence of transforaminal epidural steroid injection (TFSI) combined with caudal epidural steroid injection (CESI) on pain intensity, patient satisfaction, and quality of life in lumbar radiculopathy has not been examined., Aim: To evaluate the short and long-term efficacy of TFSI, and TFSI combined with CESI (TFSI + CESI) in patients with lumbar radiculopathy., Materials and Methods: We retrospectively examined the records of 104 patients with lumbar radicular pain and L4/5 and/or L5/S1 intervertebral disc disease who underwent TFSI or TFSI + CESI. We compared the pain intensity using a Visual Numeric Scale (VNS), North American Spine Society (NASS) pain satisfaction index, and EuroQol five dimensions (EQ-5D) quality of life scores before intervention, and after 1, 6 and 12 months., Results: In the TFSI group, the mean pre-treatment VNS score was 9.2, which improved to 4.9 after 1 month and to 7.2 after 12 months. In the TFSI + CESI group, the mean pre-treatment VNS score was 9.4, which improved to 2.6 and 4.6 after 1 and 12 months, respectively. Improvement in the VNS scores was significantly higher in the TFSI + CESI group (P < 0.0001 for each). Mean EQ-5D quality of life index in the TFSI group improved from 0.59 in the pre-treatment phase to 0.76 after 12 months of intervention, while it improved from 0.62 in the pre-treatment phase to 0.84 at 12 months of intervention in the TFSI + CESI group. The EQ-5D scores were significantly better in the TFSI + CESI group at 1, 6, and 12 months after the procedure (P = 0.004, 0.036, and 0.042, for 1, 6, and 12 months, respectively). The NASS scores were significantly better in the TFSI + CESI group at 6 and 12 months after the intervention (P = 0.025 and 0.001 for 6 months and 12 months, respectively)., Conclusion: In patients with lower lumbar radiculopathy, a combined TFSI + CESI technique offers superior short and long-term pain relief, quality of life, and long-term patient satisfaction, than when TFSI is performed alone.

Background Context: Patients with lumbosacral radiculopathy from an intervertebral disc herniation are frequently treated by transforaminal epidural steroid injections (TFESIs). The long-term outcomes of these patients are poorly described., Purpose: We aimed to determine the long-term outcomes for a homogenous group of patients with acute unilateral lumbar radicular pain due to single-level herniated nucleus after lumbar epidural steroid injection at ≥5 years., Design: This is a prospective cohort study., Patient Sample: Subjects enrolled into a previous reported multi-institutional randomized controlled trial, ≥18 years old with single leg radicular pain rating ≥4/10 for less than 6 months' duration, with radiographic imaging demonstrating an anatomically congruent single-level herniated nucleus pulposus., Outcome Measures: Presence of recurrent or persistent pain, pain within the previous week, current opioid use for radicular symptoms, additional spine injections for radicular pain, progression to surgery, and unemployment due to pain as determined by independent phone interview at least 5 years after enrolment due to the initial pain complaint were the outcome measures., Methods: All patients initially underwent a single-level lumbar TFESIs due to failure of conservative care, but could elect to pursue surgical intervention or repeat injections through shared decision making with the treating physician when and if pain control was deemed inadequate. After ≥5 years, an independent assessor contacted the subjects by phone and performed a standardized interview to determine outcomes. Fisher exact test was used to compare outcomes for those who pursued versus those who did not pursue surgery., Results: During the recruitment period (December 2008 to December 2012), 78 subjects were enrolled. At 5 years, 39 (50%) of the 78 subjects were reachable for independent phone follow-up. Of these, 30 (76.9%, 95% confidence interval [CI] 61.7%-87.4%) had a history of recurrent pain since the initial TFESI. However, only 9 (23.1%, 95% CI 12.7%-38.3%) had current pain, while 3 (7.7%, 95% CI 2.7%-20.3%) were currently taking opioid medications. Nine (23.1%, 95% CI 12.7%-38.3%) had received additional TFESIs, and 19 (48.7%, 95% CI 33.9%-63.8%) had received surgery. Only 3 (7.7%, 95% CI 2.7%-20.3%) were unemployed due to related pain at time of follow-up. When comparing the group that had surgery versus those that did not, there were no differences in the rates of recurrent pain (16, 84.2% vs. 14, 70.0%, p=.81), current pain (6, 31.6% vs. 3, 15.0%, p=.47), opioid use (2, 10.5% vs. 1, 5.0%, p=1.00), rate of additional injections (6, 31.6% vs. 3, 15.0%, p=.47), or unemployment status (2, 10.5% vs. 1, 5.0%, p=1.00)., Conclusions: Despite a high success rate at 6 months, the majority of subjects experienced a recurrence of symptoms at some time during the subsequent 5 years. Fortunately, few reported current symptoms, and a small minority required additional injections, surgery, or opioid pain medications. Lumbar disc herniation is a disease that can be effectively treated in the short-term by TFESI or surgery, but long-term recurrence rates are high regardless of treatment received., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Oral and injected steroids are used commonly in the treatment of cervical radicular pain despite a paucity of data demonstrating their efficacy. The purpose of this study is to assess whether the response to orally administered steroids among patients with acute cervical radicular pain who develop recurrent pain is associated with their subsequent response to cervical epidural steroid injections., Methods: Patients referred to our center were evaluated and then referred for cervical epidural steroid injections at the clinical discretion of the provider; those who met inclusion criteria were offered participation in the study. After the injection was administered, patients were contacted by telephone and asked to complete the Brief Pain Inventory Short Form at one week, one month, three months, and six months postinjection., Results: Pain reduction after cervical steroid injection was not significantly different between 49 patients who reported pain reduction with a prior course of oral steroids and 22 patients who reported no pain reduction. Average pain scores decreased over six months (P < 0.001) among 72 patients treated with epidural steroid injection for cervical radicular pain. Of the 55 who provided baseline and six-month data, 14 (25.5%) reported complete relief at six months and 20 (36.4%) reported decreased pain., Conclusions: Patients can be reassured that they may experience pain reduction after a cervical epidural steroid injection even if oral steroid therapy was not effective. The majority of patients treated for cervical radicular pain with epidural steroid injection have reduced or absent pain for at least six months after treatment., (© 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Objective: In patients with chronic radicular pain, we aimed to evaluate subgroup differences in 1-yr response to transforaminal epidural steroid injection., Design: In this longitudinal cohort study of 100 subjects, 170 transforaminal epidural steroid injections were performed for 1 yr. The sample was stratified by type of disc herniation (protrusion n = 57, extrusion n = 27), by location of disc herniation (central/subarticular n = 60, foraminal n = 24), by grade of nerve root compression (low-grade compression n = 61, high-grade subarticular nerve compression n = 14, high-grade foraminal nerve compression n = 25), and by positive Slump test (n = 67). Treatment response was evaluated by visual analogue scale leg pain and self-reported disability (Oswestry Disability Index). Logistic regression was used to analyze the predictive value of baseline characteristics including the stratified subgroups., Results: High-grade subarticular nerve compression predicted the 1-yr improvement in both visual analogue scale leg pain (P = 0.046) and Oswestry Disability Index (P = 0.027). Low age (P < 0.001), short duration of leg pain (P = 0.015), and central/subarticular disc herniation (P = 0.017) predicted improvement in Oswestry Disability Index., Conclusions: In patients treated with one or several transforaminal epidural steroid injections due to chronic lumbar radicular pain, clinical findings failed to predict the 1-yr treatment response. Low age, short duration of leg pain, central/subarticular disc herniation, and high-grade subarticular nerve compression predicted a favorable 1-yr response to transforaminal epidural steroid injection.

Cervical radiculopathy has become an increasing problem worldwide. Conservative treatment options have been recommended in many reviews on cervical radiculopathy, ranging from different types of physiotherapy to waiting for remission by natural history. No multimodal pain management concept (MPM) on an inpatient basis has been evaluated. This study aimed at showing the positive short-term effects of an inpatient multimodal pain management concept with focus on cervical translaminar epidural steroid injection for patients with cervical radiculopathy. 54 patients who had undergone inpatient MPM for 10 days were evaluated before and after 10-days treatment. The NRS (0-10) value for arm pain could be reduced from 6.0 (IQR 5.7-6.8) to 2.25 (IQR 2.0-3.1) and from 5.9 (IQR 4.8-6.0) to 2.0 (IQR 1.7-2.6) for neck pain. Neck pain was reduced by 57.4% and arm pain by 62.5%. 2 days after epidural steroid injection, pain was reduced by 40.1% in the neck and by 43.4% in the arms. MPM seems to be an efficient short-term approach to treating cervical radiculopathy. Cervical translaminar epidural steroid injection is an important part of this concept. In the absence of a clear indication for surgery, MPM represents a treatment option.

Objective: The purpose of this article is to review the anatomy of the lumbar neural foramen and to describe techniques of transforaminal epidural steroid injections with emphasis on safety. Rare cases of paraplegia have been reported., Conclusion: Although no consensus currently exists about which approach is the safest, knowledge of the foraminal anatomy is a key consideration when choosing a needle approach for transforaminal epidural steroid injections.

Study Design: Retrospective clinical outcome analysis., Objective: To evaluate and determine whether demographic, comorbid factors, or physical examination findings may predict the outcome of caudal epidural steroid injections in managing patients with chronic low back pain and radiculopathy SUMMARY OF BACKGROUND DATA:: The caudal epidural approach is commonly utilized with patients who are on anticoagulation or who have had prior lumbar surgery to treat L5 or S1 radiculopathies., Methods: A retrospective review of 136 patients undergoing an initial caudal epidural steroid injection for radiculopathy from January 1, 2006 to August 30, 2013. The patients were assessed before their injections for their pain levels: visual analog scale, presence of lumbar paraspinal and sciatic notch sensitivity, pain with provocative maneuvers, motor weakness, and sensory loss. The patients were then reassessed following their injection for their visual analog scale pain levels, percentage improvement, and duration of pain relief., Results: Stepwise regression was used to determine whether demographic, comorbid factors, or physical examination signs were predictive of percentage improvement or length of relief following an injection. Among these variables, duration of symptoms was found to be negatively significantly related with a P-value of 0.032 for percentage of improvement. For each week of the duration of symptoms, the percentage of improvement decreased by 0.07%. Regarding physical examination findings, presence of pain with lumbar extension was negatively and significantly related to length of relief duration with a P-value of 0.0124. The mean length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension CONCLUSIONS:: The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.

Objective: A cervical epidural steroid injection is one of the most commonly performed interventions to manage chronic neck pain and cervical radiculopathy. Despite its many severe complications, cervical transforaminal epidural steroid injection (CTFESI) is a clinically necessary modality for managing neck pain and cervical radiculopathy. We aimed in this study to find a safer optimal needle entry angle to decrease the chance of an accidental vertebral artery (VA) puncture even with a proper needle entry angle and to visualize the target of the needle tip. Methods: This retrospective study included 312 patients with neck pain or cervical radiculopathy who had undergone magnetic resonance imaging scans for diagnosis and treatment. The first line was drawn from the midpoint of the two articular pillars and passed through the exact midline of the spinous process. The second line was drawn parallel to the ventral lamina line (conventional transforaminal approach line, CTAL). The third line was drawn parallel to the ventral margin at the midpoint of the superior articular process's ventral border (new transforaminal approach line, NTAL). The angle of intersection between the midline and CTAL versus with NTAL were measured from both sides (right and left) at C5-6, C6-7, and C7-T1 levels. Also, the distance of CTAL and NTAL from VA were measured from both sides at each level. We examined whether the CTAL and NTAL would penetrate the ipsilateral VA, internal carotid artery (ICA), and internal jugular vein (IJV). Results: There were significant differences between CTAL and NTAL angles at all levels (P < 0.001). There were significant differences between the distance of CTAL and NTAL from VA at all levels (P < 0.001). There were also significant differences between the observed frequency of CTAL and NTAL that would penetrate the major ipsilateral vessel (VA, ICA, and IJV) on all levels and sides (P < 0.001~0.030). Conclusion: The angle of NTAL (approximately 70°) is safer than the angle of CTAL (approximately 50°) when considering vascular injuries to vessels, such as the VA, ICA, and IJV., Competing Interests: Competing Interests: The authors have declared that no competing interest exists.

Objective: To explore the outcome differences of lumbar transforaminal epidural steroid injection (TFESI) according to magnetic resonance imaging (MRI) findings in patients with lumbar radicular pain., Design: Retrospective study., Setting: Single university-based interventional pain management unit., Patients: Fifty-nine patients who had lumbar radicular pain with a recent lumbar MRI and three-month follow-up were included., Methods: MRI findings were reviewed for the following items: herniation type (bulging, protrusion, extrusion), herniation location (central, subarticular, foraminal, extraforaminal), high intensity zone (HIZ), and nerve root impingement (NRI). Pain severity was evaluated using a visual analogue scale (VAS) at time of before injection, then two weeks and three months after., Results: Pain scores improved significantly in each group ( P  < 0.05) at all time points, but there were no statistically significant differences in improvements according to type or location of disc herniation. Pain scores were significantly lower in patients with HIZ at the second week and in patients with NRI at the third month ( P  < 0.05)., Conclusions: TFESI was an effective treatment method in patients with radicular pain, irrespective of the type or location of disc herniation. However, greater improvement in pain may be expected at the second week in patients with HIZ and at the third month in patients with NRI., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Clinical management after epidural steroid injections (ESI) of patients with radiculopathy secondary to a cervical disc herniation (CDH) is uncertain. This study aims to determine whether short-term arm pain alleviation following computed tomography-guided 'indirect' cervical ESI can predict the 1-month outcome., Methods: We conducted a prospective observation of 45 consecutive patients at a tertiary radiological department. Study components were visual analog scale arm and neck pain at baseline, 15, 30, and 45 min, 1, 2, and 4 h, on days 1-14, 1 month, and at 1 year. Health-related quality of life and functional impairment were assessed using the short form-12 and Neck Pain and Disability Scale. Patients who reported ≥80 % persisting arm pain, as well as patients who underwent a second injection or an operation within 1 month were defined as 'non-responders'. Logistic regression was used to analyze the effect size of the relationship between >50 % pain relief at any given study visit and responder status., Results: Patients experiencing a >50 % pain reduction 4 h after the injection were four times as likely to be responders as those experiencing ≤50 % pain reduction (OR 4.04, 95 % CI 1.10-14.87). The effect was strongest on days 5-6 (OR 18.37, 95 % CI 3.39-99.64) and remained significant until day 14., Conclusions: The results of this study can guide physicians in managing patients with CDH: a ≤50 % arm pain relief within 1 week after an 'indirect' cervical ESI predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered at an earlier point in time.

Background and Objectives: No study has compared cervical interlaminar epidural steroid injection (CIESI) with epidural catheter advancement to the side and level of pathology versus standard C7-T1 CIESI. This study investigated whether cervical radicular pain is more effectively treated by CIESI with a targeted epidural catheter versus a standard C7-T1 approach., Methods: Prospective, randomized, single-blinded trial., Primary Outcome: Numerical Rating Scale (NRS) pain at 1 month., Secondary Outcomes: Oswestry Neck Disability Index (ONDI), Pain Disability Index (PDI), McGill Pain Questionnaire (MPQ), Patient Global Impression of Change (PGIC), daily morphine equivalents (DME), and Medication Quantification Scale (MQS) III scores., Results: Seventy-six participants with a median age of 48 years (IQR, 40-56 years), 59% female, with C4 (n = 2), C5 (n = 27), or C6 (n = 47) radicular pain were enrolled. At 1 month in the catheter and no catheter groups, respectively: 26 (72%, 95% confidence interval [CI], 57%-87%) and 23 (60%; 95% CI, 45%-75%) participants reported 50% or greater NRS reduction; 24 (67%; 95% CI, 52%-84%) and 23 (58%; 95% CI, 42%-73%) participants reported 30% or greater ONDI reduction. There were no group differences in median NRS, ONDI, PDI, MPQ, PGIC, DME, or MQSIII scores (P > 0.05). Intergroup differences were not observed at any follow-up interval., Conclusions: This trial showed no significant difference in clinical outcomes with CIESI using a targeted epidural catheter compared to a standard C7-T1 approach for the treatment of unilateral cervical radicular pain at the C5 or C6 level. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up.The study was registered at Clinical Trials.gov (NCT02095197).

Background: Clinical management after epidural steroid injections of patients with radiculopathy secondary to a lumbar disc herniation is uncertain. It is the aim of this study to determine whether short-term alleviation of leg pain after computed tomography-guided transforaminal epidural steroid injections can predict the 1-month outcome., Methods: Prospective observational study of 57 patients at a tertiary radiological department. Study components were visual analog scale leg and back pain at baseline, 15, 30, 45 minutes, 1, 2, and 4 hours, on days 1-14, as well as at 1 month. Health-related Quality of Life and functional impairment were assessed with the Short Form-12 and Oswestry Disability Index. Patients who reported >80% persisting leg pain, as well as patients who underwent a second injection or an operation within 1 month, were defined as nonresponders. Logistic regression was used to analyze the effect size of the relationship between >50% pain relief at any given study visit and responder status., Results: Patients experiencing a >50% pain reduction 4 hours after the injection were 3.38 times as likely to be responders as those experiencing ≤50% pain reduction (odds ratio 3.38, 95% confidence interval 1.07-10.65). The effect decreased between days 1 and 2, reappeared on day 3, was strongest on day 6 (odds ratio 6.87, 95% confidence interval 1.99-23.72), and remained significant until day 14., Conclusions: The results of this study can guide physicians in managing patients with lumbar disc herniation: a ≤50% leg pain relief within 1 week after a transforaminal epidural steroid injection predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The relationship of pain relief from a recently presented CT-guided indirect cervical nerve root injection with local anesthetics and steroids to surgical decompression as a treatment for single-level cervical radiculopathy is not clear. This retrospective study aimed to compare the immediate and 6-week post-injection effects to the short- and long-term outcomes after surgical decompression, specifically in regard to pain relief., Methods: Patients (n = 39, age 47 ± 10 years) who had undergone CT-guided indirect injection with local anesthetics and steroids as an initial treatment for single cervical nerve root radiculopathy and who subsequently needed surgical decompression were included retrospectively. Pain levels (VAS scores) were monitored before, immediately after, and 6 weeks after injection (n = 34), as well as 6 weeks (n = 38) and a mean of 25 months (SD ± 12) after surgical decompression (n = 36). Correlation analysis was performed to find potential associations of pain relief after injection and after surgery to investigate the predictive value of post-injection pain relief., Results: There was no correlation between immediate pain relief after injection (-32 ± 27 %) and 6 weeks later (-7 ± 19 %), (r = -0.023, p = 0.900). There was an association by tendency between immediate pain relief after injection and post-surgical pain relief at 6 weeks (-82 ± 27 %), (r = 0.28, p = 0.08). Pain relief at follow-up remained high at -70 ± 21 % and was correlated with the immediate pain amelioration effect of the injection (r = 0.37, p = 0.032). Five out of seven patients who reported no pain relief from injection had a pain relief from surgery in excess of 50 %., Conclusions: The amount of immediate radiculopathic pain relief after indirect cervical nerve root injection is associated with the amount of pain relief achieved at long-term follow-up after surgical decompression of single-level cervical radiculopathy. Patients can still expect sufficient pain relief from surgery even if they did not respond to the cervical infiltration.

Objective: To estimate and compare radiation exposure and intervention time during lumbar epidural steroid injection (ESI) 1) under different practitioners and methods with continuous fluoroscopic monitoring, and 2) under one practitioner with different methods and monitoring., Materials and Methods: We consecutively recruited 804 patients who underwent lumbar ESI and 759 patients who underwent 922 interventions were included for analysis in this investigation. Three different practitioners (a senior faculty member, junior faculty member, trainee) performed lumbar ESI using different methods (caudal, interlaminar, transforaminal). The senior faculty member performed lumbar ESI under two different methods of fluoroscopic monitoring (continuous [CM] and intermittent monitoring [IM]). The dose area product (DAP) fluoroscopy time, and intervention time during lumbar ESI were compared for 1) ESI methods and practitioners under CM, and 2) ESI methods and monitoring., Results: With CM, interaction between the effects of the practitioner and the intervention on DAP was significant (p < 0.001), but not fluoroscopy time (p = 0.672) or intervention time (p = 0.852). The significant main effects included the practitioner and intervention on DAP, fluoroscopy time, and intervention time with CM (p < 0.001). DAPs and fluoroscopy time for caudal, interlaminar, and transforaminal ESI were higher with CM than with IM (p < 0.001). Intervention time did not differ between CM and IM., Conclusion: Radiation exposure is dependent on the practitioners and methods and within the established safety limits during lumbar ESIs under CM. With an experienced practitioner, IM leads to less radiation exposure than CM.

Unlabelled: Epidural steroid injections have been gaining popularity as an alternative to surgical treatment of radicular pain with associated spinal derangement. To determine the effectiveness and indications of lumbar epidural steroid injections in patients with or without surgery, we performed a prospective observational study. We gathered data from 262 degenerative short-segment spinal disease patients (affected at one or 2 levels) with greater than 12 weeks of medication-resistant radicular pain without neurological deficits but with moderate disability (visual analog scale < 6.5; Oswestry Disability Index < 35). All patients received initial fluoroscopically guided transforaminal epidural steroid injections of the affected vertebral level(s) corresponding to their symptoms. Those with inadequate responses or who wanted subsequently surgery underwent decompression surgery. Clinical and demographic characteristics were assessed to compare the differences between the groups., Results: Of the 262 patients who received epidural steroid injections, 204 did not have operations for up to one year. However, 58 patients experienced inadequate relief of pain or wanted operations and therefore underwent surgery. At baseline, the 2 groups had similar mean disability indices and pain scores, as well as gender ratios, ages, and durations of symptoms (P > 0.05). In the patients who underwent surgery, the mean disability and pain scores were not significantly decreased after injection compared to those in the injection-alone group, although the scores for the injection plus surgery patients decreased significantly after surgery (P < 0.05). In contrast, patients who underwent epidural steroid injection alone experienced a significant decrease in disability and pain after injection, and that persisted up to one year of follow-up (P < 0.05). Epidural steroid injection can decrease the pain and disability in the majority of a moderate disability group for up to one year, although a significant number of patients underwent surgery regardless of injection. We recommend epidural steroid injection as a first-line treatment in patients with moderate disability that can be converted to surgery without significant delay., Key Words: Epidural steroid injection, spinal surgery, lumbar spinal disease, lumbar radiculopathy, lumbar radicular pain.

Background and Purpose: Cervical transforaminal epidural steroid injections are commonly performed for temporary pain relief or diagnostic presurgical planning in patients with cervical radiculopathy. Intravascular injection of steroids during the procedure can potentially result in cord infarct, stroke, and even death. CT-fluoroscopy allows excellent anatomic resolution and precise needle positioning. This study sought to determine the safest needle tip position during CT-guided cervical transforaminal epidural steroid injection as determined by the incidence of intravascular injection., Materials and Methods: We retrospectively evaluated procedural imaging for consecutive single-site CT-fluoroscopic cervical transforaminal epidural steroid injection performed during a 13-month period. Intravascular injections were identified and classified by volume, procedure phase, vessel type, and needle tip position relative to the targeted neural foramen. ANOVA, Wilcoxon, or Pearson χ(2) testing was used to assess differences among groups as appropriate., Results: Intravascular injections occurred in 49/201 (24%) procedures. Of the intravascular injections, 13/49 (27%) were large, 10/49 (20%) were small, and 26/49 (53%) were trace volume. Sixteen of 49 (33%) intravascular injections occurred with a trial contrast dose; 27/49 (55%), with a steroid/analgesic cocktail; and 6/49 (12%), with both. Twenty-seven of 49 (55%) intravascular injections were likely venous, 22/49 (45%) were indeterminate, and none were likely arterial. The intravascular injection rate was significantly lower (P < .001) for the extraforaminal needle position (8/82, 10%) compared with junctional (27/88, 31%) and foraminal (14/31, 45%) needle tip positions., Conclusions: An extraforaminal needle position for CT-guided cervical transforaminal epidural steroid injection decreases the risk of intravascular injection and therefore may be safer than other needle tip positions., (© 2016 by American Journal of Neuroradiology.)

Background: Steroids often are administered into the epidural space through the transforaminal epidural (TFE) route to treat lumbosacral radicular pain secondary to herniated intervertebral discs. However, their efficacy and safety compared with transforaminal epidural local anesthetics (LAs) or saline injections is unclear., Methods: We reviewed randomized controlled trials that compared TFE injections of steroids (with or without LA) with LA or saline in adult outpatients with lumbosacral radicular pain secondary to herniated intervertebral disks. Databases searched included MEDLINE, EMBASE, Cochrane central register of controlled trials, Cochrane database of systematic reviews, and Google Scholar up to February 2015. Data on scores of numerical rating scale for pain, validated scores for measuring physical disability and quality of life, and incidence of surgery measured at 1 month to 2 years after the interventions were meta-analyzed. Strength of evidence was classified with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system., Results: Eight randomized controlled trials including 771 patients (366 in steroid and 405 in comparator groups) were included. There was variability in the studies in the dose of TFE steroids, frequency, and number of procedures. Patients who received TFE steroids reported a significant, but clinically modest, reduction in mean pain scores (0-10 scale) compared with LA/saline (-0.97 points; 95% confidence interval, -1.42 to -0.51 points; P < 0.0001, I² = 90%; GRADE weak recommendation; moderate-quality evidence) at 3 months after the interventions. TFE steroids did not decrease physical disability at 1 to 3 months after the intervention (GRADE strong recommendation ↓; high-quality evidence) or incidence of surgery at 12 months after the intervention (GRADE strong recommendation ↓; moderate-quality evidence) compared with LA/saline., Conclusions: TFE steroids provide modest analgesic benefit at 3 months in patients with lumbosacral radicular pain secondary to herniated intervertebral disks, but they have no impact on physical disability or incidence of surgery. There was a high degree of heterogeneity among the publications included in this meta-analysis. Well-designed, large, randomized studies are required to evaluate appropriate dosages, adverse effects, number of procedures, and the effect of this intervention on psychological disability and quality of life.

Background: The efficacy of lumbar percutaneous epidural neuroplasty (PEN) as a minimally invasive technique has been relatively well investigated, but the clinical effectiveness of cervical PEN (C-PEN) has yet to be established., Objective: The purpose of this study was to compare clinical outcomes between C-PEN and cervical epidural steroid injection (C-ESI)., Study Design: Randomized control study., Setting: University hospital center., Methods: Eighty patients with neck pain from single level cervical disease with and without radiculopathy were included in this study. Patients were randomly assigned into 2 groups: C-PEN or C-ESI. Clinical outcomes were assessed according to Neck Disability Index (NDI) score and Visual Analog Scale (VAS) score for arm pain until 12 months after treatment., Results: All C-PEN and C-ESI groups showed better NDI recovery and greater reduction in VAS score at postoperative 6 months (P < 0.001). The C-PEN group demonstrated better NDI score at postoperative 6 months than the C-ESI group (P = 0.014), while there were no differences at 2, 4, and 12 months. Additionally, the C-PEN group showed lower VAS scores at all follow-up intervals compared to the C-ESI group (P < 0.050). Symptom relief was sustained for a significantly longer duration in the C-PEN group than in the C-ESI group (23.4 vs. 20.5 weeks, P < 0.001)., Limitations: The follow-up period was relatively short with a small sample size, and the grade of cervical disc disease, root compression, and disc degeneration grade were could not considered in this study., Conclusions: C-PEN was superior to C-ESI in terms of better NDI recovery (at 6 months) and greater reduction in VAS score (until 12 months) in treating single level cervical disc herniation. Better outcomes with C-PEN may have been achieved via a more localized selective block in the epidural space closer to the dorsal root ganglion and ventral aspect of the nerve root.

Background and Objectives: Epidural steroid injections (ESIs) are commonly performed for adults with spinal pain and/or radiculopathy. Previous pediatric ESI case series were not identified by literature review. The primary aim of this study was to examine the safety and provisional outcomes of pediatric ESIs., Methods: With institutional review board approval, medical records were reviewed for patients aged 9 to 20 years receiving a first ESI at Boston Children's Hospital from 2003 through 2013. A subset of patients completed a Web-based follow-up questionnaire. Descriptive statistics included frequencies, medians, interquartile ranges, and Kaplan-Meier methods. Statistical comparisons were made using Wilcoxon rank sum, χ2, Fisher exact, and Cox proportional hazards regression analyses., Results: A total of 224 patients aged 9 to 20 years underwent 428 ESIs. One hundred seventy-four (76.0%) patients had a lumbar disc herniation with radiculopathy; the others had a spectrum of other spinal disorders. There were no serious adverse events, hospitalizations, dural punctures, or nerve injuries. During follow-up, 69 (41.6%) of 166 previously nonoperated lumbar disc plus radiculopathy patients underwent discectomy at a median time of 128 days (interquartile range, 76-235 days) after first injection. Degrees of straight-leg raising at presentation was significantly associated with subsequent discectomy. On follow-up, patients who did and did not undergo discectomy had low pain scores and high function scores., Conclusions: Children and adolescents can receive ESIs under conscious sedation with good safety. Further prospective studies may better define the role for these injections in the comprehensive management of pediatric spinal pain disorders.

Background: Cervical transforaminal epidural steroid injections (CTFESIs) may help decrease pain and restore function in patients with cervical radiculopathy. Evidence of the injections' effectiveness, however, remains controversial, and multiple case reports have identified potential complications. Such reports have led to diminished interest in including the procedure in patient care algorithms., Objectives: Our retrospective analysis aims to evaluate the CTFESI-associated pain relief and possible decreased need for spine surgery, along with its potential predictive role in determining cervical surgical outcomes. Finally, our study intends to estimate associated complications., Methods: A pain management database registry was used to identify patients who were referred by spine surgeons for diagnostic CTFESIs in preparation for possible surgery between January 2001 and December 2009. Outcomes were defined as the incidence of cervical surgery after diagnostic injection and the associated pain relief. A Poisson distribution was used to obtain a 95% confidence interval for the incidence of complications., Results: Sixty-four patients met the inclusion and exclusion criteria. After diagnostic CTFESIs, 45 (70.3%) of the observed 64 patients did not require cervical spine surgery whereas 19 (29.7%) still did. The mean pain reduction was 4.4 units on the numeric rating scale, with no observed complications., Conclusions: This retrospective analysis further demonstrates the safety, diagnostic value, and possible therapeutic role of CTFESIs. A larger, controlled, randomized study is needed to assess definitively the procedure's efficacy and safety.

Objectives: To identify the diagnostic, therapeutic, and prognostic values of transforaminal epidural steroid injection as interventional rehabilitation for lumbar radiculopathy., Setting: Regional hospital, Hong Kong., Patients: A total of 232 Chinese patients with lumbar radiculopathy attributed to disc herniation or spinal stenosis received transforaminal epidural steroid injection between 1 January 2007 and 31 December 2011., Interventions: Transforaminal epidural steroid injection., Main Outcome Measures: Patients' immediate response, response duration, proportion of patients requiring surgery, and risk factors affecting the responses to transforaminal epidural steroid injection for lumbar radiculopathy., Results: Of the 232 patients, 218 (94.0%) had a single level of radiculopathy and 14 (6.0%) had multiple levels. L5 was the most commonly affected level. The immediate response rate to transforaminal epidural steroid injection was 80.2% in 186 patients with clinically diagnosed lumbar radiculopathy and magnetic resonance imaging of the lumbar spine suggesting nerve root compression. Of patients with single-level radiculopathy and multiple-level radiculopathy, 175 (80.3%) and 11 (78.6%) expressed an immediate response to transforaminal epidural steroid injection, respectively. The analgesic effect lasted for 1 to <3 weeks in 35 (15.1%) patients, for 3 to 12 weeks in 37 (15.9%) patients, and for more than 12 weeks in 92 (39.7%) patients. Of the 232 patients, 106 (45.7%) were offered surgery, with 65 (61.3%) undergoing operation, and with 42 (64.6%) requiring spinal fusion in addition to decompression surgery. Symptom chronicity was associated with poor immediate response to transforaminal epidural steroid injection, but not with duration of pain reduction. Poor response to transforaminal epidural steroid injection was not associated with a preceding industrial injury., Conclusions: The immediate response to transforaminal epidural steroid injection was approximately 80%. Transforaminal epidural steroid injection is a useful diagnostic, prognostic, and short-term therapeutic tool for lumbar radiculopathy. Although transforaminal epidural steroid injection cannot alter the need for surgery in the long term, it is a reasonably safe procedure to provide short-term pain relief and as a preoperative assessment tool.

Objectives: To evaluate the efficacy and safety of cervical epidural steroid injection (CESI) in the management of cervical disc herniations with radiculopathy., Method: We conducted a prospective interventional study with a 1-year follow-up comprising 33 consecutive patients presenting symptoms of cervicobrachial pain; positive neurological signs; corresponding cervical disc herniation/protrusion as verified by magnetic resonance imaging (MRI); insufficient improvement on prior conservative therapy; and no claims for financial compensation. Symptoms and clinical findings were registered in validated questionnaires before the procedure. Blind midline interlaminar CESI at the level of disc herniation was administered utilizing the loss of resistance (LOR) technique. Outcome was assessed during the first 3 months by telephone interview or clinical examination and final outcome measures were obtained at 1 year using validated questionnaires., Results: The study included 20 men (60%) and 13 women (40%); median age was 51 (range 30-63) years. Median duration of neck and arm pain was 72 (7-450) and 64 (5-443) days, respectively. On average, patients received 1.7 CESIs (range 1-3). Sixteen patients (49%) had only one injection. All 33 patients were potentially surgical candidates. Only two (6%) needed surgical intervention during follow-up. There was significant improvement in pain intensity and functional outcome. Intake of analgesics was significantly reduced. Eighty-two per cent would say 'yes' to receiving the same treatment again. No serious adverse events were observed., Conclusions: CESI appears to be a safe and efficient part of the treatment of patients with symptomatic cervical disc herniations and may be considered before patients are referred to surgery.

Objectives: To describe all the CT findings after in situ contrast injection just before steroid injection and to recognize the abnormal aspects associated with intravascular contamination., Material and Methods: We retrospectively evaluated 248 cervical transforaminal steroid injections done at the university hospital in Dijon, France, in 2008-2012, to treat cervicobrachial neuralgia inadequately improved by optimal medical treatment for at least 3 weeks. Features describing the opacification patterns were recorded., Results: Five main nonvascular opacification patterns were identified: clumps of contrast agent outside the foramen (16 %), a crab claw pattern surrounding the ganglion (13 %), a "French" circumflex accent pattern (15 %), reflux along the needle (7 %), and facet joint capsule opacification (22 %). Concerning the situations requiring a change in needle position, intravenous injection occurred in 26 % of the patients, with a crab claw pattern in half the cases and a clump pattern in half the cases. Intraarteriolar injection was noted in two patients., Conclusion: CT after in situ contrast injection ensures proper needle positioning outside the blood vessels before steroid injection. Penetration of the needle tip into a vein is very common, whereas arteriolar puncture is extremely rare.

Background: The causes of upper extremity radicular pain or neck pain are varied, often involving disc herniation, spinal stenosis, or spondylosis. Cervical transformaminal epidural steroid injection (C-TFESI) is a common treatment for such pain. However, its efficacy conceivably may depend on needle-tip placement, linking the degree of pain reduction achieved to the pattern of contrast dispersion., Objective: The current study explores this relationship, evaluating contrast dispersion patterns of C-TFESI in conjunction with short-term patient outcomes., Study Design: This study was conducted prospectively., Methods: A total of 67 patients with cervical radicular pain were enrolled, each of whom underwent computed tomography (CT)-guided C-TFESI. Procedural contrast dispersion was judged as either intraforaminal or extraforaminal. Using the Roland 5-point pain scale, outcomes were scored 2 weeks after injection and then grouped as improvement (scores, 0 - 2) or no improvement (scores, 3 - 5)., Results: Contrast dispersion was largely intraforaminal (50 patients), as opposed to extraforaminal (17 patients), with no statistically significant difference in short-term pain relief by contrast pattern (intraforaminal: 56%, 28/50; extraforaminal: 53%, 9/17; P = 0.459). Of the 50 procedures where dispersion of contrast was intraforaminal, 44% (22/50) were scored as unfavorable outcomes., Limitations: Secondary outcomes were not measured and And we did could not classification contrast spread patterns depend on epidural, epiradicular, both epidural and epiradicular vs neither due to CT could not found this anatomic structure., Conclusion: C-TFESI is an effective treatment for cervical radicular pain that is refractory to conventional conservative remedies. However, therapeutic response to C-TFESI and dispersion pattern of injected contrast failed to correlate in this study.