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Advances in medicine have made long-term survival of cancer patients possible. Hence, it is now necessary to consider how to approach common symptoms, such as cancer-related pain, in these patients. In this study, we describe a lung cancer patient in whom relief of intractable thoracic pain caused by pleural metastasis was achieved through thoracic radiofrequency thermocoagulation (RF), improving his quality of life (QOL). The patient was a man in his 70s with right upper lobe lung cancer, left 9th ?11th rib metastasis, and left thoracic pain associated with parietal pleural metastasis. The patient experienced insomnia and weight loss due to poor appetite caused by opioid analgesics and inadequate pain control. Therefore, RF was performed as interventional treatment, resulting in a decrease in the numerical rating scale score from 10/10 to 2/10, and an improvement in QOL. In cases wherein long-term survival is expected, a long-term treatment plan for chronic cancer-related pain, which has a tendency to become persistent, becomes necessary. RF for the nerve roots might be a viable option for pain caused by pleural metastasis in cancer survivors.

Back pain is one of the most common medical problems and is associated with high socioeconomic costs. Imaging-guided spinal injections are a minimally invasive method to evaluate where the back pain is originating from, and to treat patients with radicular pain or spinal stenosis with infiltration of corticosteroids. CT-guided spine injections are a safe procedure, characterized by precise needle placement, excellent visualization of the relevant anatomical structures, and low radiation exposure for the patient and the interventional radiologist. In this review article, the variety of applications of CT-guided injections (focused on nerve roots and epidural injections) and the optimal injection procedure as well as risks and side effects are discussed. [ABSTRACT FROM AUTHOR]

Abstract Purpose To investigate whether a cocktail therapy of dexamethasone, ropivacaine, dexmedetomidine, and vitamin B12 can achieve satisfactory pain relief and promote early functional recovery after PPECD. Methods Eighty single-level patients with CDH who received PPECD were retrospectively divided into two groups: the cocktail and control groups. Clinical data were recorded and evaluated by a dedicated physician who was not involved in the patient’s treatment. The primary clinical outcomes included visual analog scores (VASs) for upper limber pain and neck disability index (NDI) scores. The follow-up time points were preoperatively and postoperative 1 week, 1 month, 3 months, 6 months, and 12 months. The modified MacNab criteria was used to evaluate the surgical effect of the last follow-up. Results The follow-up data of 74 cases were complete, except 6 cases lost to follow-up. There was no significant difference between the two groups in demographics, duration of symptoms, operation stage (p > 0.05), and operation time (80.5 ± 5.5 vs. 81.5 ± 3.5 min). The VAS in the upper limbs pain was significantly higher postoperatively than preoperatively in both groups (p 0.05). In the control group, two cases with foraminal stenosis were found to have unrelieved pain in the early postoperative period, but the pain was relieved at the final follow-up and did not convert to open decompression surgery. Conclusions Cocktail treatment, in which a drug sustained-release material made of gelatin sponge was impregnated with dexamethasone, ropivacaine, dexmedetomidine and vitamin B12, facilitates pain relief and early postoperative recovery after PPECD.

Purpose: To investigate whether a cocktail therapy of dexamethasone, ropivacaine, dexmedetomidine, and vitamin B12 can achieve satisfactory pain relief and promote early functional recovery after PPECD. Methods: Eighty single-level patients with CDH who received PPECD were retrospectively divided into two groups: the cocktail and control groups. Clinical data were recorded and evaluated by a dedicated physician who was not involved in the patient's treatment. The primary clinical outcomes included visual analog scores (VASs) for upper limber pain and neck disability index (NDI) scores. The follow-up time points were preoperatively and postoperative 1 week, 1 month, 3 months, 6 months, and 12 months. The modified MacNab criteria was used to evaluate the surgical effect of the last follow-up. Results: The follow-up data of 74 cases were complete, except 6 cases lost to follow-up. There was no significant difference between the two groups in demographics, duration of symptoms, operation stage (p > 0.05), and operation time (80.5 ± 5.5 vs. 81.5 ± 3.5 min). The VAS in the upper limbs pain was significantly higher postoperatively than preoperatively in both groups (p < 0.05). The cocktail group had a lower VAS than the control group 1 week postoperatively (p < 0.05); however, VAS not different between groups at the remaining time points. The NDI scores were significantly better postoperatively than preoperatively, and no significant differences were seen when comparing nodes at postoperative follow-up (p > 0.05). In the control group, two cases with foraminal stenosis were found to have unrelieved pain in the early postoperative period, but the pain was relieved at the final follow-up and did not convert to open decompression surgery. Conclusions: Cocktail treatment, in which a drug sustained-release material made of gelatin sponge was impregnated with dexamethasone, ropivacaine, dexmedetomidine and vitamin B12, facilitates pain relief and early postoperative recovery after PPECD. [ABSTRACT FROM AUTHOR]

Back pain due to degenerative spine conditions is one of the most common causes for seeking medical care. Standard pharmaceutical and physiotherapy interventions are offered to manage the pain. However, those approaches can be insufficient, and interventional therapies may be used in addition to standard treatment. The main principle of the interventional therapy is administering the medication directly to the affected part of the spinal segment. The article reviews the main interventional techniques, their indications, and differences between them.

Introduction  Mechanical low back pain frequently originates from the lumbar facet joint (LFJ). Axial low back discomfort can result from osteoarthritis in the LFJ. Depending on the severity of LFJ degeneration, the effect of intra-articular (IA) LFJ corticosteroid injection may vary. For LFJ discomfort, IA block with steroids and local anaesthetics has also been utilised, with varying degrees of success. The main objective of this study was to assess the efficacy of IA steroid injections dexamethasone vs. triamcinolone acetonide for the treatment of LFJ syndrome and to compare functional outcome in terms of Visual Analog Scale (VAS) score, Modified Oswestry Disability Index (MODI) score, and short-form McGill Pain Questionnaire between the two groups. Methodology Dexamethasone 8 mg or triamcinolone acetonide 40 mg was given intra-articularly to 27 patients comprising group A and 33 patients comprising group B, respectively (total 60 patients). Before intervention and at one, three, and six months, observation was conducted using the VAS score, short-form McGill pain questionnaire, and MODI score. Results There was a significant difference between both the groups after the procedure with pain alleviation and functional improvement, more in the group that received triamcinolone acetonide. A significant difference was observed in all three parameters that assessed pain with differences more pronounced at six months. Conclusion Pain reduction and clinical outcomes were better among the group that received triamcinolone acetonide. Injection of a steroid alone is associated with its own side effects. When a lumbar transforaminal epidural injection is used to treat radiculopathy in the lumbar area, particulate medication (triamcinolone) is more effective than non-particulate medication (dexamethasone) with no known drug-related complications., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics Committee of Sri Devaraj Urs Medical College, Kolar, Karnataka, India, issued approval SDUMC/KLR/IEC/533/2023-24. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Gandhi et al.)

BACKGROUND: Short- or long-segment fixation is still controversial in the treatment of adult degenerative lumbar scoliosis. OBJECTIVE: To investigate the effectiveness and feasibility of accurate treatment of short-segment fixation in adult degenerative lumbar scoliosis patients assisted by highly selective nerve root block. METHODS: Thirty-five patients with adult degenerative lumbar scoliosis treated in Chinese PLA General Hospital and People’s Hospital of Peking University from May 2014 to September 2017 were analyzed retrospectively, including 14 males and 21 females aged (64.2±8.1) years. The fixation segments were determined by a highly selective nerve root block. All patients were subjected to transforaminal lumbar interbody fusion. During the follow-up, visual analogue scale score and Oswestry disability index were evaluated. Parameters including lumbar curvature Cobb angle, lumbar lordosis angle, sacral slope, and pelvic tilt and interbody fusion condition were obtained by imaging; and complications were recorded. This study was approved by the Ethics Committee of Chinese PLA General Hospital and People’s Hospital of Peking University. RESULTS AND CONCLUSION: (1) Of the 35 patients, 27 underwent single-segment minimally invasive transforaminal lumbar fusion, 5 underwent doublesegment minimally invasive transforaminal lumbar fusion, and 3 underwent three-segment minimally invasive transforaminal lumbar fusion. (2) The follow-up time of 35 patients was (25.6±1.5) months. All patients achieved the grade I fusion. Within 3 months, there were 3 cases of dural tear and cerebrospinal fluid leakage, 1 case of lower-extremity muscular venous thrombosis, 1 case of pneumonia and 1 case of wound fat liquefaction. Three months later, there was 1 case of adjacent segment degeneration; no nerve injury or nonunion, no screw or titanium rod breakage. (3) Visual analogue scale score, Oswestry disability index, Cobb angle, lumbar lordosis angle, sacral slope, and pelvic tilt at the last follow-up were significantly improved in 35 patients compared with those before surgery (P < 0.01). (4) Short-segment precision treatment of adult degenerative lumbar scoliosis with highly selective nerve root block can achieve good clinical effect. [ABSTRACT FROM AUTHOR]

Introduction: Backache and sciatic pain are routinely seen in day-to-day practice. In all urban settings with changed lifestyle, lack of exercise, bad posture, excessive use of vehicles, and disturbed nutrition; problem of discogenic backache and sciatica is on the rise. The treatment modalities vary from conservative to surgical methods, but they predominantly provide relief to leg pain and not back pain. Nerve root block acts at these inflammatory processes, by the action of the steroid and thus decreasing the chemical irritation to the nerve roots. Furthermore, there is a decrease in sensitization of dorsal horn neurons by bupivacaine. Aims and Objectives: To evaluate diagnostic and therapeutic efficacy of root block procedure. To study relief in terms of pain alleviation, activities of daily living, and straight leg raising (SLR) restriction. Materials and Methods: Retrospective study of fifty patients of sciatic radiculopathy between the ages of 20 and 60 years were evaluated under this study at Dr. D. Y. Patil Medical College and Research Centre, Pune. All the patients of different age and sex had radicular pain with or without back pain, restricted spinal mobility, positive active and passive SLR test, and other nerve tension signs. Results: Out of fifty patients selected after thorough clinical and radiological examination, 45 (90%) had enjoyed complete pain relief and 31 (62%) of which were completely symptom-free at the end of 1 year. Conclusion: Spinal nerve root block may provide lasting therapeutic benefit, allowing the patient to participate in physical therapy and early return to routine activities saving working manpower hours.

Peripheral neuropathy is a group of disorders in which the peripheral nervous system gets damaged due to conditions such as diabetes, shingles, vitamin deficiency, acquired immune deficiency syndrome (AIDS), spinal cord disorder, poisoning by heavy metals, alchohol, etc. Patients with peripheral neuropathy usually present with symptoms such as numbness, tingling, paresthesia, and weakness of the involved limb. Here, we have discussed a case of a 34-year-old male who had tingling and numbness of the right leg and right foot. However, initially, he was treated as a case of lumbar radiculopathy but was finally managed with tablets oxcarbazepine and Pregabalin in due course of time to which he responded well.

Objective Application of nerve root block is mainly for diagnosis with less application in intraoperative treatment. The aim of this study was to observe clinical and imaging outcomes of application of gelatin sponge impregnated with a mixture of 3 drugs to intraoperative nerve root block combined with robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery in to treat adult degenerative lumbar scoliosis. Methods From January 2012 to November 2014, 108 patients with adult degenerative lumbar scoliosis were treated with robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery combined with intraoperative gelatin sponge impregnated with a mixture of 3 drugs. Visual analog scale and Oswestry Disability Index scores were used to evaluate postoperative improvement of back and leg pain, and clinical effects were assessed according to the 36-Item Short-Form Health Survey. Imaging was obtained preoperatively, 1 week and 3 months postoperatively, and at the last follow-up. Fusion status, complications, and other outcomes were assessed. Results Follow-up was complete for 96 patients. Visual analog scale scores of leg and back pain on postoperative days 1–7 were decreased compared with preoperatively. At 1 week postoperatively, 3 months postoperatively, and last follow-up, visual analog scale score, Oswestry Disability Index score, coronal Cobb angle, and coronal and sagittal deviated distance decreased significantly ( P = 0.000) and lumbar lordosis angle increased ( P = 0.000) compared with preoperatively. Improvement rate of Oswestry Disability Index was 81.8% ± 7.4. Fusion rate between vertebral bodies was 92.7%. Conclusions Application of gelatin sponge impregnated with 3 drugs combined with robot-assisted minimally invasive transforaminal lumbar interbody fusion for treatment of adult degenerative lumbar scoliosis is safe and feasible with advantages of good short-term analgesia effect, minimal invasiveness, short length of stay, and good long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To assess the technical feasibility, safety and initial clinical efficacy of a combined ultrasound and fluoroscopy imaging approach to cervical nerve root blocks. Fluoroscopic guided cervical transforaminal and selective nerve root injections are often used in the investigation or treatment of radicular symptoms, although rare but serious complications including death have been reported. We report a combined technique developed to increase safety of selective nerve root injections, including the safety and early efficacy of this novel technique in our initial patient cohort.Methods: We retrospectively reviewed a consecutive cohort of injections performed in 149 patients by a single consultant radiologist between December 2010 and August 2012. For all patients the outcome was assessed both immediately following the procedure and at six weeks. Primary outcome was reduction in radicular symptom level. Duration of symptoms were also assessed and all complications were recorded.Results: One hundred and forty nine patients underwent injection at either one or two cervical levels. No patients experienced any complications during the follow-up period, and 72 % had an initial positive response to the injection. Of these, 42 % were discharged to the care of their General Practitioner, 23 % went on to have surgery, 18 % were actively monitored in a specialist clinic, 10 % were referred to our pain management service and 4 % had the injection repeated after symptoms recurred.Conclusion: Using this combined image guided technique cervical nerve root blocks appear both safe and effective in the investigation and management of radicular symptoms from the cervical spine. [ABSTRACT FROM AUTHOR]

Purpose: To provide an anatomical basis for intrusive treatment using an approach through the lateral zones of the lumbar intervertebral foramina (LIF), especially for acupotomology lysis, percutaneous transforaminal endoscopy, and lumbar nerve root block.Methods: Blood vessels, ligaments, nerves, and adjacent structures of ten cadavers were exposed through the L1-2 to L5-S1 intervertebral foramina and examined.Results: The lateral zones of the LIF were almost filled by ligaments, nerves, and blood vessels, which were separated into compartments by superior/inferior transforaminal ligaments and corporotransverse superior/inferior ligaments. Two zones relatively lacking in blood vessels and nerves (triangular working zones) were found beside the lamina of the vertebral arch and on the root of the transverse processus. Both the ascending lumbar vein and branches of the intervetebral vein were observed in 12 Kambin's triangles, and in only seven Kambin's triangles were without any veins.Conclusions: Nerves and blood vessels are fixed and protected by transforaminal ligaments and/or corporotransverse ligaments. It is necessary to distinguish the ligaments from nerves using transforaminal endoscopy so that the ligaments can be cut without damaging nerves. Care needs to be taken in intrusive operations because of the veins running through Kambin's triangle. We recommend injecting into the lamina of the vertebral arch and the midpoint between the adjacent roots of the transverse processus when administering nerve root block. Blind percutaneous incision and acupotomology lysis is dangerous in the lateral zones of the LIF, as they are filled with nerves and blood vessels. [ABSTRACT FROM AUTHOR]

Introduction: CT-guided cervical nerve root injection with corticosteroid and/or local anesthetic is a recognized technique in the evaluation and treatment of cervical radiculopathy. There are few prospective studies on the efficacy of the various techniques employed in cervical nerve root injection. We present our results from a 1-year prospective series using a CT-guided anterolateral transforaminal approach for cervical nerve root injection of bupivacaine and dexamethasone. Methods: Pain using a numeric rating scale was assessed at pre-injection, 15 min post-injection, 1 month, and 3 months. Disability was assessed using the Oswestry Neck Disability Index (NDI) questionnaire at pre-injection, 1 month post-injection, and 3 months. Results: In total, 50 patients were followed for 3 months. The mean reductions in pain were: 15 min (77 %), 1 month (39 %), and 3 months (33 %). The mean reductions in NDI were: 1 month (26 %) and 3 months (also 26 %). Results were statistically significant. Conclusions: CT-guided selective cervical nerve root injection in the treatment of cervical radicular pain and related disability produces statistically significant reductions in pain and disability to at least 3 months post-procedure. [ABSTRACT FROM AUTHOR]

The article discusses research which was conducted to investigate factors that may affect the success of fluoroscopically guided selective nerve root block, which is used to treat radicular pain and as a diagnostic tool, and to evaluate its effectiveness. Researchers evaluated 301 treatment episodes with 283 patients who were assessed over 25 months by patient questionnaire over a seven day period. They found that there was a statistically significant increase in pain relief over the seven days after the procedure, that pain provocation during the procedure did not improve analgesic success, that cervical, lumbar, and sacral level procedures were equally efficacious and that overall, 69.1% of patients experienced some pain relief by day 7. They concluded that fluoroscopic guidance did not effect the efficacy of the nerve block.

Objective: The purpose of this study is to investigate if relying on postal questionnaires returned by patients provides an accurate representation of reported outcomes from patients receiving imaging-guided lumbar nerve root injections (NRIs). Materials and methods: Patients who received imaging-guided transforaminal lumbar NRIs were given short questionnaires inquiring about pain level [numerical rating scale (NRS)] and overall improvement [Patient's Global Impression of Change (PGIC)]. Those who did not return the questionnaires (non-responders) were telephoned and asked about pain level and overall change in condition. Age and gender matching of responders and non-responders resulted in 97 patients in each group. The proportion of patients reporting clinically relevant 'improvement' or 'worsening' in each group was calculated and the Chi-square test was used to detect differences. NRS and PGIC scores for responders and non-responders were compared using Student's t test and the Mann-Whitney U test, respectively. Results: A higher proportion of non-responders reported clinically relevant improvement (53.6 %) compared to responders (42.6 %) and responders reported significantly higher levels of worsening of condition ( p = 0.01). Both responders and non-responders had significant ( p ≤ 0.05) improvement on the 20-30-min and 1-month NRS scores compared to their pre-injection baseline scores. Non-responders had significantly higher baseline NRS scores but no significant difference at the 20-30-min and 1-month NRS scores compared to responders. Conclusions: Patients returning postal questionnaires reported less favorable outcomes compared to those who did not return their questionnaires. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to describe our initial experience and to illustrate the potential benefits of using small caliber (25 and 27 G), noncutting pencil point needles (Sprotte) with single puncture coaxial technique in CT-guided spinal intervention (CTSI). From January 2009 to June 2009, Sprotte needles with single puncture coaxial technique were used in a total of ten patients for selective nerve root block (SNRB), facet joint block, and pars block under CT fluoroscopy (total of 16 target structures). All procedures were performed without conscious sedation, and visual analog scale (VAS) scores were recorded to determine pain related to needle placement. Total CT fluoroscopy time and out-of-plane needle deviation were obtained. Final needle position was documented by contrast injection for SNRBs and image capture for joint space cannulation. Sixteen out of the 16 structures were successfully targeted. No increase in VAS scores associated with needle placement was recorded, after infiltration of local anesthesia. Optimal peri-neurograms were obtained in all cases of SNRB, despite the side-hole opening in the Sprotte needles. Mean CT fluoroscopy time was 2 s (range 2–8 s per structure), and there was no case of out-of-plane needle deviation that required adjustment of the CT gantry. The use of small caliber Sprotte needles in CTSI is technically feasible and represents a potential refinement to current techniques in the management of chronic spinal pain. [ABSTRACT FROM AUTHOR]

The article presents a study that evaluates the effectiveness of L5 nerve root block technique under ultrasound guidance and electrical nerve stimulation. It notes that the research involved 78 patients with L5 radicular syndrome. Its findings showed that all patients, except the 3 whom nerve block could not be conducted, had experienced decreased sensation at L5 neural region and had fully resolved pain after nerve block.

Steroid injections are often employed as an alternative treatment for radicular pain in patients with degenerative spinal disorders. Prospective randomised studies of the lumbar spine reveal contradictory results and non-randomised and most often retrospective studies of the cervical spine indicate pain reduction from steroid injections. No prospective randomised study on transforaminal steroid injections for the treatment of radicular pain in the cervical spine focusing on short-term results has been performed. Forty consecutive patients were employed for the study. The inclusion criteria were one-sided cervical radiculopathy with radicular distribution of arm pain distal to the elbow and corresponding significant degenerative pathology of the cervical spine at one or two levels on the same side as the radicular pain and visualised by MRI. A transforaminal technique was used for all injections. A positive response to a diagnostic selective nerve root block at one or two nerve roots was mandatory for all patients. The patients were randomised for treatment with steroids/local anaesthetics or saline/local anaesthetic. Only the neuroradiologist performing the blocks was aware of the content of the injection; all other persons involved in the study were blinded. Follow up was made 3 weeks after the randomised treatment by a clinical investigation and with a questionnaire focusing on the subjective effects from the injections. At follow up, there were no differences in treatment results in the two patient groups. Statistical analysis of the results confirmed the lack of difference in treatment effect. Further studies have to be performed before excluding steroids in such treatment and for evaluating the influence of local anaesthetics on radiculopathy in transforaminal injections. [ABSTRACT FROM AUTHOR]

Transforaminal injections are sometimes used for the diagnosis and treatment of painful conditions in the lumbar and to a lesser degree in the cervical spine. The technique is most often used when investigating/treating radiculopathy caused by degenerative disease. But how selective are the nerve root blocks? What possible structures other than the intended nerve root are affected from such injections? This study was undertaken in order to try to answer these questions, as no study focusing on the possible spread from the transforaminal selective nerve root blocks in the cervical spine has been performed earlier. In three groups of patients, each group including three patients, we injected three different volumes (0.6, 1.1 and 1.7 ml) with a transforaminal technique in the cervical spine. In all the injections, a small amount of contrast media was added. The spread of the injections were then investigated using multi-slice computed tomography with reconstructions. The imaging revealed a possible effect on other nerve roots than the intended ones when a larger volume was used for the root blocks. The spread was related to the injected volume as well as to local anatomy (size of foraminal area). In this study, only 0.6-ml injections could be accepted for being selective enough for diagnostic investigations. [ABSTRACT FROM AUTHOR]

Background context: Lumbar nerve root blocks and epidural steroid injections are frequently employed in the management of degenerative conditions of the lumbar spine, but relatively few papers have been published that address the complications associated with these interventions. Serious complications include epidural abscess, arachnoiditis, epidural hematoma, cerebrospinal fluid fistula and hypersensitivity reaction to injectate. Although transient paraparesis has been described after inadvertent intrathecal injection, an immediate and lasting deficit has not been previously described as sequelae of a nerve root block.Purpose: We present three cases in which either persisting paraplegia or paraparesis occurred immediately after administration of a lumbar nerve root block and propose a mechanism for this devastating but previously unreported complication.Study design/setting: Case reports of three patients.Patient sample: Three patients, two women and one man ranging in age from 42 to 64 years, underwent three procedures performed at three different facilities, in the hands of two different injectionists. In each instance, penetration of the dura was not thought to have occurred. In two procedures the needles were placed transforamenally, one at L3–4 on the left and one at L3–4 on the right, and in the third the needle tip was placed immediately lateral to the S1 nerve root.Outcome measures: Patient follow-up data from medical office records.Methods: In each case, needle placement was verified with injection of a contrast media in conjunction with either computerized tomography or biplanar fluoroscopy. No backbleeding or cerebrospinal fluid was encountered upon aspiration in any of the procedures. Magnetic resonance imaging (MRI) was performed within 48 hours of injury in all patients.Results: In each patient, paraplegia suddenly ensued after instillation of the steroid solution and, in each instance, postprocedure MRI revealed increased signal in the low thoracic spinal cord on T2-weighted imaging consistent with edema. The sudden onset of neurological deficit and the imaging changes noted in the spinal cord point to a vascular explanation for these injuries. We postulate that in these patients the spinal needle either penetrated or caused injury to an abnormally low dominant radiculomedullary artery, a recognized anatomical variant. This vessel, also known as the artery of Adamkiewicz, in 85% of individuals arises between T9 and L2, usually from the left, but in a minority of people may arise from the lower lumbar spine and rarely even from as low as S1. The artery of Adamkiewicz travels with the nerve root through the neural foramen and irrigates the anterior spinal artery. Injury of it or injection of particulate matter into it, as what may happen with the commonly used epidural steroid injectates, may result in infarction of the lower thoracic spinal cord, producing the clinical and imaging findings seen in these three patients.Conclusions: We present the cases of three patients who had lasting paraplegia or paraparesis after the performance of a nerve root block. We propose that the mechanism for this rare but devastating complication is the concurrence of two uncommon circumstances, the presence of an unusually low origin of the artery of Adamkiewicz and an undetected intraarterial penetration of the procedure needle. [Copyright &y& Elsevier]

Aims: Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure., Methods: OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented., Results: Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described., Conclusion: There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: Bone Joint J  2022;104-B(5):567-574.

A selective lumbosacral nerve root block is generally is performed under X-ray fluoroscopy, which has the disadvantage of radiation exposure and the need for fluoroscopy equipment. In this study, we assessed the effectiveness of ultrasound and nerve stimulation-guided S1 nerve root block on 37 patients with S1 radicular syndrome. With the patient in a prone position, an ultrasound scan was performed by placing the probe parallel to the body axis. The needle was pointed slightly medial from the lateral side of the probe and advanced toward a hyperechoic area in the sacral foramina with ultrasound guidance. Contrast medium was then injected and its dispersion confirmed by fluoroscopy. The acquired contrast images were classified into intraneural, perineural, and paraneural patterns. The significance of differences in the effect of the block among the contrast image patterns was analyzed. After nerve block, decreased sensation at the S1 innervated region and pain relief was achieved in all patients. No significant difference was noted in the effect of the block between perineural and paraneural patterns. In conclusion, this technique provided reliable S1 nerve root block in patients with S1 radicular syndrome and minimized radiation exposure. [ABSTRACT FROM AUTHOR]

Objective: To establish a management strategy for multi-segment lumbar lateral recess stenosis., Methods: A retrospective study was performed in patients in whom suspected responsible nerve roots underwent sequential selective nerve root block (SNRB). Based on pain remission rate after blocking, the contribution of nerve root compression to symptoms was classified as absolutely (≥70%) or relatively (30-70%) responsible or non-responsible (<30%). Conservative treatment was continued if visual analogue scale (VAS) at 3 days after blocking a single nerve root or VAS at 3 days after blocking multiple nerve roots was ≥50%; otherwise, percutaneous transforaminal endoscopic discectomy (PTED) was performed. Pain and functional scores were evaluated on day 3, 6 months and 1 year after SNRB or PTED., Results: Fifty-seven of 80 patients had a single absolutely responsible root, 20 had 2 responsible roots, and 3 had 3 responsible roots. Among them, 41, 10, and 1 patient underwent PTED, respectively. Both the PTED and conservative groups improved significantly in VAS remission rate and functional scores compared with admission. Moreover, the PTED group had a better VAS remission rate compared with the conservative group., Conclusion: A combination of SNRB with PTED was effective for diagnosing and treating multi-segment lumbar lateral recess stenosis.

Objective To observe effect of application of gelatin sponge impregnated with a mixture of 3 drugs to intraoperative nerve root block to promote early postoperative recovery of lumbar disc herniation. Methods Retrospective analysis was performed of 265 patients with single-level lumbar disc herniation from January 2013 to October 2017. Patients were divided into intervention and control groups based on intraoperative application of gelatin sponge impregnated with a mixture of 3 drugs. All patients underwent unilateral minimally invasive surgical transforaminal lumbar interbody fusion. Clinical data, including bedridden period, postoperative hospital stay, visual analog scale scores for low back pain and leg pain, Japanese Orthopaedic Association score, postoperative satisfaction questionnaire results, and therapeutic effect, were collected. Results There were 136 cases in the intervention group and 129 cases in the control group. The intervention group had significantly shorter bedridden period and postoperative hospital stay than control group ( P < 0.05). Visual analog scale scores for low back pain and leg pain at postoperative days 1–10 were significantly lower in the intervention group compared with control group ( P < 0.05). The Japanese Orthopaedic Association score at postoperative day 6 and satisfaction at 72 hours postoperatively were significantly higher in the intervention group than in control group ( P < 0.05). Clinical effect at postoperative day 6 was significantly better in the intervention group than control group ( P < 0.05). Conclusions Application of gelatin sponge impregnated with a mixture of 3 drugs to intraoperative nerve root block can significantly promote early postoperative recovery of lumbar disc herniation and has great short-term clinical efficacy. [ABSTRACT FROM AUTHOR]

Background context Pain as a consequence of nerve root compression may not be easy to diagnose. Degenerative changes causing nerve root compression on magnetic resonance imaging (MRI) are common but not necessarily symptomatic while the distribution of pain attributable to a particular nerve root is variable. Selective dorsal root ganglion blocks (DRGBs) have been used in these situations to aid the diagnostic process, although their use remains controversial. Purpose We sought to investigate the positive predictive value of DRGBs in predicting response to decompressive surgery on a particular nerve root in a patient cohort with diagnostic uncertainty after clinical examination and MRI. Study design/setting This was a retrospective review of prospectively collected data on 100 consecutive patients. Methods One hundred consecutive patients who underwent diagnostic DRGB under the senior author were identified retrospectively. Clinical records were reviewed for the reason for diagnostic uncertainty, level assessed, whether the DRGB reproduced pain typical for the patient's symptoms, whether there was anatomically appropriate sensory and motor disturbance, whether good pain relief was achieved, and whether they had good response to surgery. Results Of 100 patients recruited, four were removed from analysis owing to inadequate surgical decompression proven on postoperative MRI. Of the remaining 96 patients, 74 achieved immediate relief in their symptoms after DRGB. Fifty-one patients underwent surgical decompression after a successful root block; 41 patients achieved a good result from this surgery, and 10 did not. Nine patients who had no relief in their symptoms from DRGB still underwent surgery to decompress the same nerve root; six patients had relief of their symptoms from surgery, two did not respond, and one was lost to follow-up. The most common reason for diagnostic uncertainty was multilevel disease (74%) followed by patients with atypical pain (23%). The most common level assessed was the L5 nerve root. The positive predictive value was found to be 80.4%, the negative predictive value was 22.2%, with a sensitivity of 85.4% and a specificity of 16.7%. Conclusions In patients with diagnostic doubt, a positive DRGB is a good predictor of a positive outcome after surgery to decompress that nerve root. However, the negative predictive value is poor. This result could almost certainly be improved if there was a better definition of what constitutes a positive, and more importantly a negative, DRGB result. In the meantime, DRGBs are a useful adjunct in predicting the outcome of decompressive surgery in people with pain as a consequence of potential lumbosacral nerve root compression. [ABSTRACT FROM AUTHOR]