Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study.

By London Spine
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Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study.

Skeletal Radiol. 2013 Jan;42(1):69-78

Authors: Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y

Abstract
OBJECTIVES: To compare the short-term effects and advantages of ultrasound-guided selective nerve root block with fluoroscopy-guided transforaminal epidural block for radicular pain in the lower cervical spine through assessment of pain relief, functional improvement, and safety.
METHODS: A total of 120 patients with radicular pain from cervical spinal stenosis or cervical herniated disc were enrolled. All procedures were performed using a fluoroscopy or ultrasound apparatus. The subjects were randomly assigned to either the fluoroscopy (FL) or ultrasound (US) group. The complication frequencies during the procedures, treatment effects, and functional improvement of the nerve root block were compared at 2 and 12 weeks after the procedures.
RESULTS: Verbal Numeric Pain Scale (VNS) improved 2 weeks and 12 weeks after the injections in both groups. Statistical differences were not observed in VNS, Neck Disability Index (NDI), and effectiveness between the groups. In 21 patients at US, vessels were identified at the anterior aspect of the foramen. Eleven patients had a critical vessel at the posterior aspect of the foramen and five patients had on artery continue medially into the foramen, forming, or joining a segmental feeder artery. In both cases, the vessels might well have been in the pathway of the needle correctly positioned under fluoroscopic guidance. Five cases of intravascular injections were observed only in FL without significant difference between the groups.
CONCLUSIONS: The US-guided method may facilitate identifying critical vessels at unexpected locations relative to the intervertebral foramen and avoiding injury to such vessels, which is the leading cause of the reported complications from cervical transforaminal injections. On treatment effect, using either method of epidural injections to deliver steroids for cervical radicular pain, secondary to herniated intervertebral disc or foraminal stenosis, significant improvements in function and pain relief were observed in both groups after the intervention. However, significant difference was not observed between the groups. Therefore, the ultrasound-guided method was shown to be as effective as the fluoroscopy-guided method in pain relief and functional improvement, in addition to the absence of radiation and avoiding vessel injury at real-time imaging.

PMID: 22609989 [PubMed – in process]

[Selective, microsurgical cross-over decompression of multisegmental degenerative lumbar spinal stenoses : The “Slalom” technique].

By London Spine
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[Selective, microsurgical cross-over decompression of multisegmental degenerative lumbar spinal stenoses : The “Slalom” technique].

Oper Orthop Traumatol. 2013 Feb;25(1):47-62

Authors: Mayer HM, Heider F

Abstract
OBJECTIVE: Selective, bilateral multisegmental microsurgical decompression of lumbar spinal canal stenosis through separate, alternating cross-over approaches.
INDICATIONS: Two- and multisegmental degenerative central and lateral lumbar spinal stenoses.
CONTRAINDICATIONS: None (however, if stabilization is necessary, the Slalom technique is not possible).
SURGICAL TECHNIQUE: Minimally invasive, muscle-sparing and facet-joint-sparing bilateral decompression of the lumbar spinal canal through 2 or more alternating microsurgical cross-over approaches from one side.
POSTOPERATIVE MANAGEMENT: Early mobilization 4-6 h postoperatively. Soft lumbar brace for 4 weeks (optional).
RESULTS: Between December 2010 and May 2011, the operation was performed in 35 patients (10 women; 25 men; age 71.8 years). The average time of surgery was 42 min/segment, the average blood loss was 20.3 ml/segment. Of the 35 patients, 15 did not required wound drainage. All patients were mobilized without restriction after 4-6 h, hospitalization was 5.2 days. There were 3 intraoperative complications (2 Dura lesions [5.7%] and 1 temporary L5 radiculopathy probably due to swelling of the L5 nerve root [2.8%]). Postoperatively there was a significant improvement in quality of life as measured with EQ 5D and Oswestry Disability Index as well as a significant improvement of walking distance and standing time.

PMID: 23400667 [PubMed – in process]

Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report.

By London Spine
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Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report.

J Med Case Rep. 2012;6(1):142

Authors: Tofuku K, Koga H, Komiya S

Abstract
INTRODUCTION: Although uncommon, selective cervical nerve root blocks can have serious complications. The most serious complications that have been reported include cerebral infarction, spinal cord infarction, transient quadriplegia and death.
CASE PRESENTATION: A 40-year-old Japanese woman with a history of severe right-sided cervical radicular pain was scheduled to undergo a right-sided C6 selective cervical nerve root block using a transforaminal approach under fluoroscopic guidance. An anterior oblique view of the C5-C6 intervertebral foramen was obtained, and a 23-gauge spinal needle, connected to the normal extension tube with a syringe filled with contrast medium, was introduced into the posterior-caudal aspect of the C5-C6 intervertebral foramen on the right side. In the anteroposterior view, the placement of the needle was considered satisfactory when it was placed no more medial than halfway across the width of the articular pillar. Although the spread of the contrast medium along the C6 nerve root was observed with right-sided C6 radiculography, the subdural flow of the contrast medium was not observed with real-time fluoroscopy. The extension tube used for the radiculography was removed from the spinal needle and a normal extension tube with a syringe filled with lidocaine connected in its place. We performed a negative aspiration test and then injected 1.5 mL of 1.0% lidocaine slowly around the C6 nerve root. Immediately after the injection of the local anesthetic, our patient developed acute flaccid paralysis, complained of breathing difficulties and became unresponsive; her respiratory pattern was uncoordinated. After 20 minutes, she regained consciousness and became alert, and her muscle strength in all four limbs returned to normal without any sensory deficits after receiving emergent cardiorespiratory support.
CONCLUSIONS: We believe that confirming maintenance of the appropriate needle position in the anteroposterior view by injecting local anesthetic is important for preventing central needle movement. Because the potential risk of serious complications cannot be completely eliminated during the use of any established selective cervical nerve root block procedure, preparation for an emergency airway, ventilation and cardiovascular support is indispensable in cases of high spinal cord anesthesia.

PMID: 22657834 [PubMed]