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ORIGINAL ARTICLE
Year : 2011  |  Volume : 59  |  Issue : 5  |  Page : 685--689

The efficacy of transforaminal epidural steroid injections in lumbosacral radiculopathy

Chinmoy Roy1, Nilay Chatterjee1, Satya Narayan Patro2, Amit Chakraborty3, GR Vijay Kumar3, Robin Sengupta3,  
1 Department of Pain Management, Institute of Neurosciences, Kolkata, West Bengal, India
2 Department of Interventional Neuroradiology, Institute of Neurosciences, Kolkata, West Bengal, India
3 Department of Neurosurgery, Institute of Neurosciences, Kolkata, West Bengal, India

Correspondence Address:
Chinmoy Roy
Department of Pain Management, Institute of Neurosciences-Kolkata, 185/1 AJC Bose Road, Kolkata - 700 017, West Bengal
India

Abstract

Background: Transformational epidural steroid (TFES) is commonly used to treat lumbosacral radicular pain. However, very few studies have systematically evaluated the quality of analgesia following such procedures with respect to time. Objective: To evaluate long-term efficacy of TFES in patients with lumbosacral radiculopathy. Materials and Methods: A prospective study including 30 patients having lumbosacral radiculopathy secondary to prolapsed disc. Outcome variables were the amount of improvement just after the procedure and thereafter at 24 hrs, 1 month, 6 month and 1 year post-procedure, respectively, using visual analog scale (VAS) and numeric rating scale (NRS). Patients also filled Roland-Morris questionnaire pre-procedure, 6 month and 1 year follow-up. All patients received Ibuprofen for 3 days following the procedure, to alleviate post- procedural pain. An option of rescue surgery was reserved in case of unbearable pain (>7 VAS), appearance of sudden motor deficit or if patient opts for surgery. Same injection was repeated if at any point of time pain had >5 in VAS. Results: As per NRS, almost all patients had complete pain relief (mean 98%) immediate postprocedure. At 24 hrs, the score was 79%, at 1 month 60%, at 6 months 58.5% and at 1 year 59%. Preprocedure VAS was 9.2 and thereafter 0.6, 1.8, 3.9, 3.8 and 4.2 at similar time points. Roland-Morris score was 18/24, 10/24, 9/24, at pre-procedure, at 6 months and at 1 year, respectively. No complication was noted in any patient except post procedural local pain. Conclusion: Quality of pain relief produced by TFES was significant. Long-term quality of pain relief was better in patients with pain duration less than 6 months. Even though, the study was designed to inject the drug once, many of the patients required second injection. A further study with multiple injections at prefixed time interval might probably result in a better overall outcome.



How to cite this article:
Roy C, Chatterjee N, Patro SN, Chakraborty A, Vijay Kumar G R, Sengupta R. The efficacy of transforaminal epidural steroid injections in lumbosacral radiculopathy.Neurol India 2011;59:685-689


How to cite this URL:
Roy C, Chatterjee N, Patro SN, Chakraborty A, Vijay Kumar G R, Sengupta R. The efficacy of transforaminal epidural steroid injections in lumbosacral radiculopathy. Neurol India [serial online] 2011 [cited 2021 Dec 5 ];59:685-689
Available from: https://www.neurologyindia.com/text.asp?2011/59/5/685/86541


Full Text

 Introduction



Sciatica is the term generally used for lumbosacral radiculopathy, [1] which is commonly caused by disc herniation, although a space occupying lesion in the lumbosacral spine or spondylolisthesis can also result in such clinical condition. About 10-15% of patients with lumbosacral radiculopathy eventually require surgery [2],[3] but overall the majority recover with conservative management. [4],[5],[6] Studies suggest inflammation of the affected nerve roots in the mechanism of pain. [7],[8],[9] The inflammatory component has attracted the use of corticosteroids to decrease inflammation and thus reduction in pain. Steroid injections have been used through different routes as an alternative to surgery or adjunct to conservative therapy. Epidural steroid injection has been used for treatment of lumbosacral radiculopathy, [10],[11] with varying success rates, 20- 80% [12],[13] and efficacy lasting for an average period of not more than 3 months. These divergent results are because of various methodological and technical limitations in the studies. [14],[11] Epidural injections when performed through translaminar or caudal approaches without fluoroscopy and contrast are likely to miss the perceived target area in 30-40% instances. [15] Moreover, it remains questionable whether an adequate concentration of the corticosteroid could be delivered to the target tissues by such approaches, irrespective of the use of fluoroscope. [10] The transforaminal epidural steroid injection (TFES), using fluoroscopy and contrast permits a high concentration of corticosteroid at the target site, which is the ventral aspect of the lumbar root sleeve and the dorsal aspect of herniated disc. [16] Recent studies have supported the efficacy of TFES for prolapsed disc. [17] However, till date very few studies have demonstrated the long-term outcome and efficacy of TFES in lumbosacral radiculopathy due to herniation of nucleus pulposus (HNP) in an objective manner. We present a study of TFES in 30 patients and evaluate the efficacy with respect to time and also the quality of analgesia.

 Materials and Methods



This is a prospective pilot study of 30 patients presenting to a tertiary care neurosciences center with lumbosacral radiculopathy secondary to prolapsed disc, as demonstrated by magnetic resonance imaging (MRI). The study has the approval of the Institutional Ethical Committee. Inclusion criteria included: 1) adult patients capable of giving informed consent after understanding the treatment options available, and capable of complying with the outcome measures used in the study; 2) patients primarily having leg pain greater than back pain and a typical dermatomal pattern associated with limitation of straight-leg-raise to less than 45 degree, and with prolapsed intervertebral disc (PIVD) confirmed by MRI; and 3) all patients have undergone conservative treatment for at least 4 weeks. All patients were referred by the neurosurgeon and were newly diagnosed cases eligible for surgery. Patients opted voluntarily for nonsurgical alternatives after being explained the management options, and surgery would be the next intervention if TFES injection fails. Patients were excluded if they had motor deficit, previous back surgery, history of substance abuse, signs of infection, coagulopathy, history of allergy to local anesthetic or any drug, osteophytes, extruded or migrated disc, spondylolisthesis or severe spinal deformity and inability to comply with the measures of outcome analysis.

All the injections were performed by the lead author under fluoroscopic guidance while the patient was lying in prone position [Figure 1]. The nerve root to be infiltrated was determined by the referring surgeon and the interventional pain physician together after consultation. Typically S1 nerve root was located in S1 dorsal foramen, L5 nerve root in L5- S1 intervertebral foramina, L4 in L4-L5 foramina and so on. Multilevel injections were given in many patients depending on the diagnosis. TFES injection was delivered through the 'safe triangle' [Figure 2] which comprised of a roof made by the pedicle of vertebra, a tangential base corresponding to the exiting nerve root and the lateral border of the vertebral body. Fluoroscopy was started with anterior-posterior view and then mild craniocaudal tilt was applied to view the upper end plate of the lower vertebra as a single line. Next step was to give 10-20 degree oblique tilt to place the needle under the pedicle using the tunnel view. Lateral X-ray confirmed the position of the needle at the ventral aspect of the foramen. At each level 1-2 ml of contrast medium iohexol (omnipaque 300) was injected to outline the nerve root [Figure 3] and [Figure 4]. Epidural spread was also expected with 2 ml of contrast. Drug was never injected in case of any doubt regarding the pattern of spread of the contrast. Methylprednisolone acetate (Depomedrol 0.5 ml/20 mg) and preservative free 0.5% bupivacaine (1.5 ml/7. 5 mg) were injected together in a single syringe per nerve root. Altogether 33 patients, intended to be followed-up for a period of 1 year, were included in this study. Three patients were lost for follow-up and the final analysis included 30 patients. Patients had received an average of 1.3 TFES injections (range 1-2 TFES) at the very first session. Nine patients required repetition of same injections at an average time interval of 4.2 months. All patients had received Ibupropofen for first 3 post-procedure days to alleviate procedural pain. Subsequent to the procedure, all patients were directed to consult same physiotherapist for back-strengthening exercises, starting after day-7 of the procedure.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Treatment outcomes were measured by visual analog scale (VAS), numeric rating scale (NRS), and Roland-Morris low back pain and disability questionnaire. For measuring VAS a standard 10 cm scale was used where 0 corresponded to 'no pain' and 10 to 'worst pain' patient had ever perceived. A NRS (101 point) with options ranging from 0 (no pain) to 100 (worst pain experienced in the last 1 week) was used. Roland-Morris questionnaire was filled by the patient thrice, preprocedure, after 6 months and after 1 year. VAS and NRS outcome measures were collected just after the procedure, after 24 hrs, at 1 month, 6 month and at 1 year. All results were recorded by an independent investigator who was not involved in the interventional procedures. A successful outcome of the treatment was defined as improvement of at least 60% after 12 months of the procedure. All results were expressed in mean ± SD. For VAS and Roland-Morris scores preprocedure and postprocedure values at different time points were compared with ANOVA test. SPSS (version 17.0) was used for analysis.

 Results



As per NRS, almost all patients had complete pain relief (overall 98%, with 100% in 28 and 80% in 2 patients) immediate after the procedure. After 24 hrs, average pain relief was 79%, after 1 month 60%, after 6 months 58.5% and after 1 year it remained at 59%. VAS was 9.2 (preprocedure) and thereafter 0.6, 1.8, 3.9, 3.8 and 4.2, respectively, at similar time points. Roland-Morris score was 18/24, 10/24, 9/24, at preprocedure, at 6 months and at 1 year, respectively. No complication occurred in any of our patients, but post procedural local pain was experienced by all the patients. No one required or opted for rescue surgery but TFES injection had to be repeated in nine patients at different time intervals (average 4.2 months) [Table 1] and [Table 2].{Table 1}{Table 2}

 Discussion



The rationale for using epidural steroids originates from the studies showing abnormal concentrations of nociceptive and inflammatory mediators, around lumbosacral disc herniations causing a chemical neuroradiculitis. [18],[19] Corticosteroids, by inhibiting prostaglandin synthesis, limit both cell-mediated and humoral immune responses. These drugs also stabilize cellular membranes and blocks nociceptive C-fiber conduction. [20],[21],[22] Systemic search of the literature reveals the efficacy of lumbosacral epidural steroid injection for radicular pain ranging from 0 to 100% and usually lasting for less than 3 months. [12],[9] The possible explanations for the high rates of success with TFES include: 1) precise delivery of the steroid bupivacaine solution; 2) antinociceptive and membrane stabilisation properties of both the agents; 3) potent anti-inflammatory properties of the steroid; and 4) washout effects of the solution causing decreased levels of interleukin 1 (IL 1), tumor necrosis factor (TNF) and phospholipase-chief factors mediating inflammation.

Patients in the present study showed significant amount of improvement at 1 year with TFES. Maximum pain relief was immediately after the procedure which was obviously due to the local anaesthetic effect. Selection of newly diagnosed nonoperated cases with no spinal deformity, drug delivery after typical dye spread coupled with additional rehabilitation with graded exercises may explain the relative longer duration of pain relief with lesser injections in our patients.

Older techniques/interventions for lumbosacral radiculopathy e.g., trigger point injections and lumbar/caudal epidural steroid injections are far less effective compared to TFES. These procedures require more volume of injectate as they get distributed over the entire epidural space and not delivered or confined to the exact site of pathology, thus reducing the potential therapeutic effects of corticosteroids needed to treat chemical radiculitis. The use of fluoroscopically guided TFES allows precise delivery of the medication reliably to the interface between HNP and the ventral aspect of the irritated nerve root. [10] The absence of complications like dural puncture and excessive bleeding that usually complicate blind epidural injections confirms the safety of fluoroscopically guided TFES approach. Factor associated with reduced success include the duration of symptoms for more than 6 months. It is strongly supported by the fact that all the patients requiring second session belonged to this category. Average time for reinjection was 4.2 months in our study, which has actually affected the results at 6 months and at 1 year, compared to pain relief at 1 month. Overall result at 1 year might have been influenced by the beneficial effects of exercise and physiotherapy. We have used three instruments to assess the outcomes. VAS showed postprocedure improvement rating as compared to preprocedure rating. NRS on the other hand compared the worst pain that was experienced by the patient in the last 7 days, this averaging was required, as a patient might have perceived lesser pain just prior to the procedure compared to other days.VAS recorded the pain present and NRS recorded the pain relieved. Again Roland-Morris low back pain and disability questionnaire provided the improvement in quality of life because of pain relief.

In summary, this study showed TFES is a reliable method of providing statistically significant long term pain relief in patients having lumbosacral radiculopathy secondary to HNP. The results did not reach to the level of our expectation, as uniform 60% improvement was not achieved after 1 year interval (VAS-54.3%, NRS-59%, RM-49.4%). However, the long-term outcome trend is indeed encouraging. A further study with a greater number of patients and with multiple sessions of injections at prescheduled interval will confirm the beneficial effects of this mode of treatment. The limitations of the present study include a relatively small patient population, comparatively small follow-up period limited to 1 year, treatment protocol with a single injection and exclusion of all complicated patients

References

1Merskey H, Bogduk N. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. 2 nd ed. Seattle: IASP Press; 1994.
2Bush K, Cowan N, Katz DE, Gishen P. The natural history of sciatica with associated disc pathology: A prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976) 1992;17:1205-12.
3Colonna PC, Fredienburg ZB. The disc syndrome; results of the conservative care of patients with positive myelograms. J Bone Joint Surg Am 1949;31A:614-8.
4Hakelius A. Prognosis in sciatica. A clinical follow-up of surgical and nonsurgicaltreatment. Acta Orthop Scand Suppl 1970;129:1-76.
5Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: An outcome study. Spine (Phila Pa 1976) 1989;14:431-7.
6White AH, Derby R, Wynne G. Epidural injections for the diagnosis and treatment of low back pain. Spine (Phial Pa 1976) 1980;5:78-86.
7Olmarker K, Myers RR. Pathogenesis of sciatic pain: Role of herniated nucleus pulposus and deformation of spinal nerve root and dorsal root ganglion. Pain 1998;78:99-105.
8Brisby H, Olmarker K, Larsson K, Nufu M, Rydevik B. Proinflammatory cytokines incerebrospinal fluid and serum in patients with disc herniation and sciatica. Eur Spine J 2002;11:62-6.
9Koboyashi S, Baba H, Uchida K, Kokubo Y, Kubota C, Yamada S, et al. Effect of mechanical compression on the lumbar nerve root: Localization and changes of intraradicular inflammatory cytokines, nitric oxide, and cyclooxygenase. Spine (Phila Pa 1976) 2005;30:1699-705.
10Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: An outcome study. Arch Phys Med Rehabil 1998;79:1362-6.
11Robecchi A, Capra R. Hydrocortisone (compound F); first clinical experiments in the field of rheumatology. Minerva Med 1952;98:1259-63.
12Bogduk N, Brazenor G, Christophides N, Cherry D, Fraser R, Jenkins J, et al. Epidural use of Steroids in the Management of Low Back Pain and Sciatica of Spinal Origin: Report of the Working Party. Sydney: National Health and Medical Research Council; 1993. p. 102-6.
13Carrette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997;336:1634-40.
14Koes BW, Schoelten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections for low back pain and sciatica: A systematic review of randomized clinical trials. Pain 1995;63:279-88.
15Weinstein SM, Herring SA, Derby R. Contemporary concepts in spine care: Epidural steroid injections. Spine (Phila Pa 1976) 1995;20:1842-6.
16Derby R, Kine G, Saal JA, Reynolds J, Goldthwaite N, White AH, et al. Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine (Phila Pa 1976) 1992;17 (6 Suppl): S176-83.
17Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 2010;11:1149-68.
18Marshall LL, Trethewie ER, Curtain CC. Chemical radiculitis: A clinical, physiological, and immunological study. Clin Orthop Relat Res 1977;129:61-7.
19Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine (Phila Pa 1976) 1990;15:683-6.
20Kantrowitz F, Robinson DR, McGuire, MB, Levine L. Corticosteroids inhibit prostaglandin production by rheumatoid synovia. Nature 1975;258:737-9.
21Rinehart JJ, Balcerzak SP, Sagone AL, Lo Buglio AF. Effects of corticosteroids on human monocyte production. J Clin Invest 1974;56:1337-43.
22Dilke TF, Burry HC, Grahame R. Extradural corticosteroid injection in the management of lumbar nerve root compression. Br Med J 1973;2:635-7.20).