Epidural Steroid Injections
Periradikuläre TherapieThe definition of interlaminar in the dictionary is placed between layers. Bedeutung von "interlaminar" im Wörterbuch Englisch. Synonyme und Antonyme von interlaminar auf Englisch im Synonymwörterbuch. Zitate, Bibliographie und Aktuelles übe interlaminar auf Englisch. From the early modeling work of Hayashi inand the definitive experiments
lumbar transforaminal epidural steroid injection
Transforaminal Epidural steroid injections TFESI have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency PRF administered to a targeted dorsal root ganglion DRG and TFESI for the treatment of radicular pain due to disc herniation.
Forty-four patients that met the inclusion criteria were enrolled. To evaluate pain intensity were assessed by VAS. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. Steroids are powerful anti-inflammatory agents, and effectively reduce nerve root inflammation produced by disc herniation or a disc pathology near the epidural space.
Epidural steroid injections are widely and conventionally used to alleviate and control radicular pain effectively. In particular, care should be taken to control blood sugar levels in patients with diabetes mellitus after an epidural steroid injection 6.
Radiofrequency RF treatment involves continuous stimulation and ablates nerves and tissues by increasing temperature around the RF needle tip 7 , and thus, RF treatment involves nerve ablation. However, pulsed radiofrequency PRF uses a brief stimulation period followed by a long resting phase, which exposes target nerves and tissues to an electric field without producing sufficient heat to cause structural damage 8 , 9.
Several studies have reported PRF stimulation modulates susceptibility to radicular pain without causing tissue damage, and observational studies on PRF application to dorsal root ganglia DRGs also concluded the technique appears both effective and relatively safe for the treatment of cervical and lumbar radicular pain Because PRF procedure does not need require the injection of any material, it is certain to be free of the adverse effects associated with TFESI, and thus, offers the possibility of providing a method of treating radicular pain in a safer manner.
For these reasons the present randomized controlled study was aimed at determining the effectiveness of PRF for treating radicular pain due to disc herniation and comparing its outcomes with those of TFESI. Each procedure was conducted by the physician who had experience spine interventions over more than 25 years. Subjects with cervical and lumbar radicular pain was proved by physical examination and imaging studies corresponding with clinical manifestations.
Patients were supine for cervical procedure and prone position for lumbar under C-arm fluoroscopy Siemens, Erlangen, Germany. To focus the target, C-arm was rotated toward the region and controlled the cranial-caudal angle for focusing the intervertebral foramen. A gauge with 90 mm spinal needle with a bend at the tip was inserted into the skin and advanced to the anterior half of superior articular process at cervical spine and to the 6 o'clock position below pedicle at lumbar spine.
Then, the depth of needle tip checked by anterior posterior view and lateral view of C-arm. Test dose of contrast medium 0. Then, the further injection of contrast medium was performed under real-time fluoroscopic monitoring. Finally, patients received 2 mL of 0. Aseptic techniques were adopted for PRF therapy. Pain intensities were assessed by VAS for arm and leg radiating pain, before treatment, and 2, 4, 8 and 12 after treatment.
ODI and NDI were obtained to evaluate functional disabilities associated with lumbar and cervical radicular pain, respectively, at the same times. Adverse effects were carefully evaluated at each visit to detect pain flare-up and newly developed neurologic deficits after the procedures.
Statistical analysis was conducted using SPSS ver. This prospective randomized study was conducted at a spine specialist clinic in a university hospital after obtaining institutional review board approved for the study protocol YUMC , which also complied with the tenets of the Helsinki declaration. All study subjects provided written informed consent before study commencement.
However, five patients were lost to follow up and one patient in the PRF group experienced a pain flare up and dropped out. The demographic characteristics of the subjects were shown in Table 1. However, no significant intergroup difference was observed at any time point.
One patient complained of aggravated radicular pain at 4 weeks post-PRF, and exited the study. However, the effectivenesses of the two modalities were similar over the first 3 post-procedural months. Herniated nucleus pulposus have been reported to cause inflammation and ectopic firing in affected DRGs and spinal nerves, such as, glial activity in the spinal cord and the release of pain-modulating substances by activated glia 15 , 16 , which are involved in the development and maintenance of chronic neuropathic pain associated with central sensitization 17 , Accordingly, activated glia are considered modulators of nociception and neuropathic pain.
The rationale behind epidural steroid injection for disc herniation stems from the observation that inflammatory and nociceptive mediators concentrate around herniated discs in the epidural space 19 , 20 , Steroid treatment is well known to have excellent anti-inflammatory effects that ca decrease inflammation in DRGs, spinal nerves, and in the epidural space.
One study showed steroid injection effectively reduces the gadolinium enhancement an indicator of nerve inflammation of spinal nerves associated with herniated discs Accordingly, TFESI was chosen in the present study as an initial treatment option for severe radicular pain after disc herniation.
The transforaminal approach, unlike the interlaminar and caudal approaches, enables steroid to be administered to target sites 21 , 24 , 25 , In another study, fluoroscopically guided TFESI was found to be effective at alleviating radicular pain and reducing need for surgery 28 , 29 , We are advocates of TFESI because we believe it is an effective modality for the management of spinal radicular pain. The majority of these adverse effects concern the administration of steroid and contrast media 5 , The side effects of steroid administration include facial flushing, high blood sugar, and transient headaches, and the major complications of repeated steroid injection include suppression of pituitary adrenal axis, hypocorticism, Cushing's syndrome, osteoporosis, steroid myopathy, and epidural lipomatosis.
Catastrophic adverse events have also been reported, even when TFESI is conducted by well trained physicians, the injection of particulate steroid into an artery around the spinal canal can occlude capillaries and arterioles and cause spinal cord and cerebellar infarction resulting in permanent motor and sensory deficits Recently, the non-particulate steroid, dexamethasone, was used to minimize or eliminate embolic events after TFESI 32 , On the other hand, PRF does not require the injection of steroid, contrast material, or local anesthetic, and thus, is not liable to the catastrophic adverse effects associated with vascular occlusion.
Instead, PRF uses pulses of high voltage that produces an electric field around a needle tip and then allows heat to dissipate, and thus, stimulates the targeted dorsal root ganglion and the dorsal horn. It has been shown application of PRF at a DRG, but not at the sciatic nerve, caused the up- regulation of activating transcription factor 3 an indicator of cellular stress in DRG neurons In another study, pulsed RF stimulation caused neuronal changes at targeted dorsal root ganglia and in neurons of the superficial dorsal horn, which could be associated with pain processing In a rat model of lumbar disc herniation, DRG stimulation using PRF attenuated microglial activation in the ipsilateral dorsal horn and reduced pain-related behavior as evidence by reduced mechanical withdrawal thresholds.
Therefore, it appears DRG stimulation by PRF influences neural systems involving in pain processing by modulating glial activities closely associated with progression and maintenance of central sensitization, and thus, DRGs are frequently chosen as targets to modulate electrophysiological change and modulate central sensitization after disc herniation.
Although observed histochemical changes and increases in neural markers after DRG stimulation by PRF do not constitute a mechanism for PRF, these observations do show that PRT-induced electric fields induce neural system and gene expressional changes in DRGs and the dorsal horn Several studies that addressed chronic radicular pain have reported DRG stimulation by PRF appears to offer an effective and safe intervention for cervical and lumbar radicular pain.
Similarly, Bozem et al. These encouraging outcomes for the treatment of chronic radicular pain might suggest central sensitization can be modulated by suppressing glia activity in the dorsal horn. However, the above-mentioned studies did not include comparable controls or validate the benefits of DRG stimulation by PRF in subacute radicular limb pain.
Thus, our study subjects might have exhibited incomplete suppression of inflammation around DRGs and spinal nerves after 1st TFESI, which we believe may have produced similar outcomes in the two groups. Disc herniation increases potential for generating ectopic discharges at dorsal root ganglion, which produces central sensitization.
However, this is the first randomized, controlled study directly to compare the effectivenesses of DRG stimulation by PRF and TFESI and validate the alternatives for the treatment of subacute radicular pain. The majority of studies conducted on the effectiveness of PRF for the treatment of radicular pain have reported no serious adverse events, but several authors have reported flare up of pain or temporary pain aggravation 10 , 39 , In the present study, one patient experienced temporary aggravated radicular pain, which subsided after several days.
Although PRF is a less destructive procedure than conventional radiofrequency treatment and does not cause neurologic deficits, PRF can cause microscopic neuronal damage, endoneural edema, and pathologic changes in myelin, possibly due to the heat generated at the electrode tip. We presume that these effects could explain the temporary aggravation of radicular pain experienced on occasion.
Although PRF is also minimally invasive procedure that has a possibility to destruct structure, we suggest if repeated TFESI is needed or a patient has a medical condition requiring consideration with respect to the administration of steroid, such as, uncontrolled diabetic mellitus, PRF be considered a useful clinical option for the control of subacute radicular pain that helps reduce or avoid the possible catastrophic adverse effects of TFESI.
This work was supported by the Yeungnam University Research Grant. All of the authors have no potential conflicts of interest to disclose. Study concept and design: National Center for Biotechnology Information , U. J Korean Med Sci. Published online Jun Find articles by Dong Gyu Lee. Find articles by Sang-Ho Ahn. Find articles by Jungwon Lee. Received Apr 21; Accepted Jun This article has been cited by other articles in PMC. Abstract Transforaminal Epidural steroid injections TFESI have been widely adopted to alleviate and control radicular pain in accord with current guidelines.
Inclusion criteria Age between 20 and 70 years. Imaging findings of a cervical or lumbar intervertebral disc pathology compatible with pain symptoms. Exclusion criteria Severe allergy to injectants.
Outcome measurements Pain intensities were assessed by VAS for arm and leg radiating pain, before treatment, and 2, 4, 8 and 12 after treatment. Adverse events Adverse effects were carefully evaluated at each visit to detect pain flare-up and newly developed neurologic deficits after the procedures. Ethics statement This prospective randomized study was conducted at a spine specialist clinic in a university hospital after obtaining institutional review board approved for the study protocol YUMC , which also complied with the tenets of the Helsinki declaration.
Open in a separate window. Table 1 Demographic characteristics. Table 2 Statistical results of cervical procedures by two-factor repeated measures analysis. Table 3 Statistical results of lumbar procedures by two-factor repeated measures analysis. Adverse events One patient complained of aggravated radicular pain at 4 weeks post-PRF, and exited the study. Foraminal injection for lateral lumbar disc herniation.
J Bone Joint Surg Br. Fluoroscopic transforaminal lumbar epidural steroids: Arch Phys Med Rehabil. Transforaminal epidural steroid injections in lumbosacral radiculopathy: Complications of fluoroscopically guided transforaminal lumbar epidural injections. Cervical transforaminal injection of corticosteroids into a radicular artery: Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus.
Effects and side effects of a percutaneous thermal lesion of the dorsal root ganglion in patients with cervical pain syndrome. A comparison of the neuroablative effects of conventional and pulsed radiofrequency techniques.
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Tureng - lumbar transforaminal epidural steroid injection - Türkisch Englisch Wörterbuch
Der Bandscheibenvorfall (lat. Prolapsus nuclei pulposi, auch Bandscheibenprolaps (BSP), .. The dosages of corticosteroid in transforaminal epidural steroid injections for lumbar radicular pain due to a herniated disc. Pain Physician ; Eine periradikuläre Therapie (PRT) ist die perkutane Applikation von Medikamenten lokal an Der Schmerz 15(6),(). Scanlon et al.: Cervical transforaminal epidural steroid injections: more dangerous than we think ? Spine J. Bedeutungen von dem Begriff "lumbar transforaminal epidural steroid injection" im Türkisch Englisch Wörterbuch: 1 Ergebniss(e).