Epidural Steroid InjectionOz show aired a show covering epidural epirural. Paul Lynch, an interventional pain physician from Arizona, presented the pro side of the transforaminal epidural steroid injection youtube injections, while Dr. Jan Friedly, who isgenuinely opposed to epidural injections, presented the con view. Surprisingly, the show included an investigative testosterone sale which was both inaccurate and inappropriate with no data to back them up. The only data they had was in reference to the number of epidural injections approximately 9 million performed in the Transforaminal epidural steroid injection youtube. A few of the points that were made in this "Undercover Investigative Report" on the show are as follows:
Epidural Steroid Injection - Pain Doctor
Desai, Binit Shah, Puneet K. To evaluate the relationship between commonly used final needle-tip positions and subsequent contrast flow and patient-reported pain relief in transforaminal epidural steroid injections TFESIs. Outcome measures included ventral and dorsal epidural contrast flow as well as near-to-complete pain relief as measured by numerical rating scale pain score pre- and post-procedure. Further efforts should focus on demonstrating efficacy while optimizing safety.
Epidural injections have been used in the treatment of low back pain since the beginning of the 20th century, when Cathelin used a caudal cocaine injection to treat sciatica in . Although local anesthetics were the first agents investigated for this purpose, they have since been largely replaced by the widespread use of corticosteroids.
This change was brought about by the work of Lindahl and Rexed, who found that inflammation played a role in patients with disc herniation and radicular pain . Therefore, corticosteroid preparations should prove useful given their ability to inhibit peri-neural inflammation, a possible basis for radicular pain [3,4].
The caudal route was the first used  to deliver medication to the epidural space. Even when the practitioner was confident about placement, fluoroscopy revealed it to be inaccurate Questionable delivery of therapeutic agent prompted the development of the interlaminar route. Ultimately, evidence-based research has shown that clinical judgment alone is not enough for consistently successful entry into the epidural space via an interlaminar approach [6—8].
In studies in which the incorrect placement rate was low, 1. The popularity of fluoroscopically guided transforaminal epidural steroid injection TFESI is a result of constant innovation in developing safer, more efficacious nonsurgical techniques to treat patients with low back pain and radicular symptoms.
A need to reliably deliver medication to the epidural space combined with a growing sophistication of the etiology of radicular pain has led to the prominent use of fluoroscopically guided TFESI. Theoretically, these injections have the advantage of delivering the injectate to the ventral epidural space, and therefore the commonest site of pathology in disc herniations.
Despite advances in the corticosteroid preparation used, the approach to the epidural space and the use of image guidance, a significant minority of patients have not obtained relief from this procedure. Specifically, placement either ventrally in the SA quadrant vs dorsally in the superior-posterior SP quadrant of the neural foramina may impact flow.
Safety and efficacy must both be accounted for in selecting which quadrant of the neural foramina is to be utilized. In considerations of efficacy, achieving adequate ventral flow and ultimately positive health outcomes for the patient—i. While novel techniques for needle placement in the epidural space are being explored [18—20] , further refinement of the already well-tolerated, relatively safe  and efficacious [22,23] procedure of TFESI should be explored.
We retrospectively evaluated commonly used final needle-tip position in TFESI as a marker for subsequent contrast spread and pain relief, specifically in the SA and SP quadrants of the neural foramina.
Further refinement of the method to reliably and accurately deliver injectate to the site of pathology may prove useful in guiding physician practice patterns and improve efficacy. Subjects underwent the procedure via a standardized technique in the operating room with routine monitors including blood pressure, pulse oximetry, and heart rate. The subjects were placed prone on the operating table, and the injection site was prepared in a sterile fashion.
Either a or gauge and a 3. Upon final needle-tip position, antero-posterior AP and lateral views of the fluoroscopic imaging were obtained to confirm needle positioning Images 1—6. The use of contrast 2—3 mL of Isovue [Bracco Diagnostics, Princeton, NJ] was used to illustrate the exact flow of contrast prior to the injection of the final mixture. AP and lateral views of the contrast spread were taken during the procedure to confirm appropriate spread.
Transforaminal approach, superior-anterior needle-tip position. Demonstrating ventral flow at one vertebral level.
Transforaminal approach, superior-anterior needle-tip position, left-sided. Note contrast flow along L4 nerve root. Transforaminal approach, superior-posterior needle-tip position.
Demonstrating dorsal flow at one vertebral level. Demonstrating ventral and dorsal flow at one vertebral level. Image 7 is an example of a lateral view detailing the four quadrants as they would be visualized during the procedure.
The neural foramen was bisected with a coronal and axial plane. We evaluated the most commonly utilized placements in our practice A,B. We assessed contrast flow in a cohort of subjects undergoing TFESI as part of their routine course of care. The intervertebral level of the injection was also noted.
Pre- and post-injection pain scores using the numerical rating scale NRS were also obtained. A post-injection score of 0—1 was defined as near-to-complete relief.
This information was retrieved from the subjects' medical record devoid of any identifying information. All injections were performed by an experienced, board-certified pain medicine physician MJD using bi-planar fluoroscopic imaging with non-ionic contrast. Continuous imaging was used during contrast injection in the AP and lateral planes to confirm that contrast did not spread to the intravascular, intradiscal, subarachnoid or subdural spaces.
Injections were performed as per the routine standard of care. Subjects were included if: Subjects were excluded if: Eight hundred seventy were excluded as summarized in Figure 1. The outcome measures were ventral and dorsal flow of contrast spreading in the epidural space and the proportions of subjects achieving near-to-complete pain relief, based on final needle-tip position Tables 1 and 2 , respectively. Fluoroscopic images were used to derive these measurements AP and lateral views.
Contrast flow was categorized below Table 1. Dorsal spread was either present or absent. Ventral flow was first characterized as present or absent. If ventral flow was present, further delineation as to the number of levels and direction of spread was recorded.
Statistical testing was performed using Fischer's exact test. In the SP group, There was no statistically significant difference in the direction of flow when anterior flow had spread to more than one vertebral level in any direction.
Secondarily, reduction in pain score post-injection relative to the pre-injection baseline was recorded using the NRS. These subjects had follow-up appointments between 2—4 weeks post-injection. Of the subjects having undergone TFESI with the SA needle-tip position, the respective mean pre- and post-injection pain scores were 6.
The evolution of TFESIs has been precipitated by the need to optimize safety while demonstrating efficacy. Increasingly there are reports of catastrophic complications, including paraplegia, following TFESI . This has placed an even greater burden on the clinician to prioritize safety, possibly at the expense of efficacy.
This study offers some guidance regarding the efficacy of a generally well-tolerated and safe procedure. Inherently, there is an assumption that epidural flow should be reliable despite needle placement in a specific quadrant of the neural foramina.
Several potential reasons exist for SP placement: In some cases, there is a tendency for SP placement of the needle due to relative ease and the desire to avoid parasthesias. Consideration of which quadrant is to be utilized should occur for each patient, weighing that patient's specific anatomy and pathology and the current evidence to ultimately decide which quadrant will lead to optimal flow of injectate to the site of pathology.
TFESIs are typically performed for ventral epidural pathology, hence utilizing ventral contrast flow as a predictor of future injectate delivery should prove advantageous.
Furthermore, an assessment of images provided in that publication did not demonstrate ventral flow via lateral parasagittal ILESI. This analysis demonstrates the superiority of SA needle-tip position vs SP position with regards to ventral contrast flow.
Furthermore, SA placement resulted in a greater number of levels with demonstrable flow suggesting an increased volume delivered ventrally. On the other hand, despite Theoretically, achieving flow at a greater number of vertebral levels suggests superior coverage of the site of pathology in the ventral epidural space.
The SP needle-tip position demonstrated greater posterior flow than the SA needle-tip position. Conceivably, for clinical scenarios with dorsal epidural disease or more generalized pathology, such as multifactorial spinal stenosis, this may be a more ideal placement.
This was determined by the subjective nature of reporting NRS and an anecdotal threshold to limit further injections in the immediate future. Subjects in the SA group were four times as likely as those in the SP group to demonstrate near-to-complete pain relief.
Limitations of this study included its retrospective design. The study was also limited by the fact that it presents a snapshot of contrast flow. Dynamic testing following standing or other motions that incorporated gravity may result in shifting of contrast and ultimately injectate. However, dynamic testing would result in further exposure to radiation. This study simply suggests where the majority of contrast, and therefore injectate is delivered.
Other limitations included uncontrolled concomitant therapies; however, we suspect that this would not result in undue variance due to a relatively standardized approach to patients with these diagnoses in our practice.
No adverse events were identified during chart review as reported by patients undergoing TFESI that were included in our analysis. Ultimately, the SA needle-tip position demonstrated superiority with regards to ventral contrast flow as well as pain relief.
These findings contribute to the body of knowledge informing physician decision-making in performing TFESIs. There is a high degree of variability in the technique regarding epidural injections, and the standard of care is constantly changing as new methods are discovered and established methods are further delineated.
Furthermore, SA placement results in greater likelihood of near-to-complete pain relief. In the setting of suspected ventral pathology, the SA approach should be the technique of choice following considerations of other issues. Certainly, a prospective study assessing contrast flow with needle placement including all four quadrants should be considered in the effort to mitigate risk and evaluate efficacy.
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