Transforaminal Epidural Steroid Injections Followed by Mechanical Diagnosis and Therapy to Prevent Surgery for Lumbar Disc Herniation.

Pain Med. 2014 May 7;

Authors: van Helvoirt H, Apeldoorn AT, Ostelo RW, Knol DL, Arts MP, Kamper SJ, van Tulder MW

STUDY DESIGN: Prospective cohort study.
OBJECTIVE: To report the clinical course of patients with MRI-confirmed lumbar disc herniation-related radicular noncentralizing pain who received transforaminal epidural steroid injections (TESIs) and mechanical diagnosis and therapy (MDT).
SUMMARY OF BACKGROUND DATA: Noncentralizing symptoms in patients with lumbar disc herniation are associated with poor outcome. Commonly used treatments for these patients include TESIs and MDT. No study has evaluated the outcome of combining both strategies.
METHODS: Consecutive candidates for herniated lumbar disc surgery with noncentralizing chronic pain were eligible. Patients received TESIs followed by MDT. The primary outcomes were pain severity in the leg, disability (Roland-Morris Disability Questionnaire for Sciatica), and global perceived effect (GPE). Outcomes were measured at baseline, discharge, and 12 months. Linear mixed-models and McNemar’s tests were used to analyze outcome data.
RESULTS: Sixty-nine patients receive TESIs. After TESIs, symptoms were resolved completely in 11 patients (16%). In these patients, symptom resolution was maintained at 12 months. A second subgroup of 32 patients (46%) reported significantly less pain after TESIs and showed centralization with MDT reassessment (significant reductions in leg pain and disability [P < 0.001]) and a satisfaction rate of 90% at 12 months. A third subgroup of 11 patients (16%) reported significantly less pain after TESIs but still showed noncentralization with MDT reassessment (significant reductions in leg pain and disability [P < 0.05] and a satisfaction rate of 50% at 12 months). A fourth subgroup of 15 patients (22%) did not respond on TESIs and received an operative intervention.
CONCLUSION: The results indicate that a course of TESIs followed by MDT may be able to avoid surgery in a substantial proportion of candidates for herniated lumbar disc surgery.

PMID: 24800697 [PubMed – as supplied by publisher]

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Trainee involvement in transforaminal epidural steroid injections associated with increased incidence of vasovagal reactions.

PM R. 2014 Apr 19;

Authors: Schneider B, Kennedy DJ, Casey E, Smuck M, Conrad B, Plastaras C

OBJECTIVES: To evaluate if trainee involvement (Resident and fellow) during transforaminal epidural steroid injections (TFESI) results in higher rates of vasovagal reactions.
DESIGN: Retrospective study on consecutive patients SETTING: Single Academic Medical Center with multiple attending physicians and trainees.
PARTICIPANTS: 2642 consecutive subjects undergoing 4482 TFESI were analyzed from 3/8/2004 to 1/30/2009 MAIN OUTCOME MEASURES: Pearsons chi square test was used to determine the relationship between vasovagal reactions and level of trainee involvement.
RESULTS: A total of 4482 TFESIs were performed, with 157 (3.5%) of procedures complicated by a vasovagal reaction. An attending physician performed 2884 (64.3%) procedures without trainee involvement, with only 79 (2.7%) vasovagal reaction noted. A fellow was involved in 723 (16.1%) procedures, with 30 (4.1%) noted to have a vasovagal reaction. A resident was involved in 875 (19.5%) procedures, with 48 (5.5%) having a vasovagal reaction. Overall, trainees were involved in 1598 (35.7%) cases, of which 78 (4.9%) were complicated by vasovagal reaction. When a trainee was involved in the case, there was a higher incidence of vasovagal episodes (p<.001, Χ(2) = 16.047). Although there was a trend towards higher vasovagal rates with residents over fellows, this did not reach statistical difference.
CONCLUSIONS: Vasovagal reactions can occur with spine injection procedures and may result in premature procedure termination or other adverse events. Although this retrospective study has significant potential for bias, it appears that trainee involvement in a TFESI is associated with a higher incidence of vasovagal reaction (p<.001, Χ(2) = 16.047).

PMID: 24755514 [PubMed – as supplied by publisher]

Outcomes of fluoroscopically guided lumbar transforaminal epidural steroid injections in degenerative lumbar spondylolisthesis patients.
Asian Spine J. 2014 Apr;8(2):119-28
Authors: Kraiwattanapong C, Wechmongkolgo…

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Optimal Angle of Needle Insertion for Fluoroscopy-Guided Transforaminal Epidural Injection of L5.

Pain Pract. 2014 Apr 1;

Authors: Ra IH, Min WK

BACKGROUND: Unlike other sites, there is difficulty in performing TFESI at the L5-S1 level because the iliac crest is an obstacle to needle placement.
OBJECTIVE: The objective of this study was to identify the optimal angle of fluoroscopy for insertion and advancement of a needle during L5 TEFSI.
METHODS: We conducted an observational study of patients undergoing fluoroscopy-guided L5 TFESI in the prone position. A total of 80 patients (40 men and 40 women) with radiating pain of lower limbs were enrolled. During TFESI, we measured the angle at which the L5 vertebral body forms a rectangular shape and compared men and women. Then, we measured area of safe triangle in tilting angle of fluoroscopy from 15° to 35° and compared men and women.
RESULTS: The mean cephalocaudal angle, where the vertebral body takes the shape of a rectangle, was 11.0° in men and 13.9° in women (P = 0.007). In men, the triangular area was maximal at 18.3 mm² with an oblique view angle of 25°. In women, the area was maximal at 23.6 mm² with an oblique view angle of 30°. At an oblique view angle of 30° and 35°, the area was significantly greater in women (P < 0.05).
CONCLUSION: When TFESI is performed at the L5 region in the prone position, placement of fluoroscopy at a cephalocaudal angle of 11.0° and an oblique angle of 25° in men and cephalocaudal angle of 13.9° and an oblique angle of 30° in women would be most reasonable.

PMID: 24690186 [PubMed – as supplied by publisher]

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