• The Korean Journal of Pain
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• 제27권2호
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• pp.168-173
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• 2014

Background: Recently, there have been several case reports and retrospective studies about the incidence of intradiscal (ID) injection during transforaminal epidural steroid injection (TFESI). Inadvertent ID injection is not a rare complication, and it carries the risk of developing diskitis, although there has been no report of diskitis after TFESI. We prospectively evaluated the incidence of inadvertent ID injection during lumbar TFESI and analyzed the contributing factors. Methods: Ten patients received 2-level TFESI, and the remaining 229 patients received 1-level TFESI. When successful TFESI was performed, 2 ml of contrast dye was injected under real-time fluoroscopy to check for any inadvertent ID spread. A musculoskeletal radiologist analyzed all magnetic resonance images (MRIs) of patients who demonstrated inadvertent ID injection. When reviewing MRIs, the intervertebral foramen level where ID injection occurred was carefully examined, and any anatomical structure which narrowing the foramen was identified. Results: Among the 249 TFESI, we identified 6 ID injections; thus, there was an incidence of 2.4%. Four patients had isthmic spondylolisthesis, and the level of spondylolisthesis coincided with the level of ID injection. We further examined the right or left foramen of the spondylolisthesis level and identified the upward migrated disc material that was narrowing the foramen. Conclusions: Inadvertent ID injection during TFESI is not infrequent, and pain physicians must pay close attention to the type and location of disc herniation.

• Journal of Yeungnam Medical Science
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• 제36권2호
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• pp.109-114
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• 2019

Background: Transforaminal epidural block (TFEB) is an effective treatment option for radicular pain. To reduce complications from intravascular injection during TFEB, use of imaging modalities such as real-time fluoroscopy (RTF) or digital subtraction angiography (DSA) has been recommended. In this study, we investigated whether DSA improved the detection of intravascular injection during TFEB at the whole spine level compared to RTF. Methods: We prospectively examined 316 patients who underwent TFEB. After confirmation of final needle position using biplanar fluoroscopy, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under RTF; 30 s later, 2 mL of nonionic contrast medium was injected at a rate of 0.5 mL/s under DSA. Results: Thirty-six intravascular injections were detected for an overall rate of 11.4% using RTF, with 45 detected for a rate of 14.2% using DSA. The detection rate using DSA was statistically different from that using RTF (p=0.004). DSA detected a significantly higher proportion of intravascular injections at the cervical level than at the thoracic (p=0.009) and lumbar (p=0.011) levels. Conclusion: During TFEB at the whole spine level, DSA was better than RTF for the detection of intravascular injection. Special attention is advised for cervical TFEB, because of a significantly higher intravascular injection rate at this level than at other levels.

• The Korean Journal of Pain
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• 제31권2호
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• pp.125-131
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• 2018

Background: The thoracic transforaminal epidural block (TTFEB) is usually performed to treat herpes zoster or postherpetic neuralgia (PHN). Especially, multiple segmental involvements and approximate contrast medium spread range, according to volume, help to choose the proper drug volume in the transforaminal epidural block. This study investigated the contrast medium spread patterns of 1-ml to 3-ml TTFEBs. Methods: A total of 26 patients with herpes zoster or PHN were enrolled in this study. All participants received 1 ml, 2 ml, or 3 ml of contrast medium. Results were divided into Groups A, B and C based on the volume (1, 2, or 3 ml), with n = 26 for each group. After the injection of contrast medium, the spread levels were estimated in both the lateral and anteroposterior (AP) images using fluoroscopy. Results: The cephalad spread of contrast medium in the lateral image as expressed by the median (interquartile range) was 2.00 levels (1.00-2.00) for Group A, 2.50 (2.00-3.00) for Group B, and 3.00 (2.00-4.00) for Group C. The caudal spread level of contrast medium was 1.00 (1.00-2.00) for Group A, 2.00 (2.00-3.00) for Group B, and 2.00 (2.00-3.00) for Group C. There was ventral and dorsal spread of the 3-ml contrast medium injection in 88% (23/26) of cases in the lateral image. Conclusions: Injection of 3 ml of contrast medium through the foramina spread 6 levels in a cephalocaudal direction. Spread patterns revealed a cephalad preference. TTFEB resulted in dorsal and ventral spread in a high percentage of cases. This procedure may be useful for transferring drugs to the dorsal and ventral roots.

• The Korean Journal of Pain
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• 제22권1호
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• pp.52-57
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• 2009

Background: Transforaminal epidural injection (TEI) may be useful to treat unilateral pain that has a dermatomal distribution. In this approach, the needle tip can be placed closer to the dorsal root ganglion and ventral aspect of the nerve root. However many studies have reported that serious complications following TEI occurred more frequently when it was conducted at the cervical level. One of the presumptive mechanisms of the complication is intravascular injection. Therefore this study was conducted to identify the incidence of complications in response to intravascular injections at cervical segments. Methods: This study included all patients, who visited our pain clinic and had radicular symptoms or herpes zoster associated pain. All procedures were conducted under fluoroscopic guidance with contrast enhancement by one of the authors. After the ideal needle position was confirmed by biplanar fluoroscopy, the blood aspiration through the needle hub was evaluated, and a 3 ml mixture of nonionic contrast (2 ml) with normal saline (1 ml) was injected at a rate of 0.3-0.5 ml/sec continuously under real time fluoroscopic visualization. We then classified the contrast spreading pattern as neural, simultaneous neural and vascular, or vascular. Results: A total 71 cervical TEIs were performed. In 26 cases (36.6%), the contrast only spread to the nerve sheath. However, 45 cases (63.4%) showed an intravascular spreading pattern, 37 (52.1%) of which showed a neural and vascular pattern and 8 (11.3%) of which showed only a vascular pattern. Conclusions: Approximately two thirds of the cases of cervical TEI were found to lead to intravascular spreading, which is much higher than the incidence reported in previous studies.

• Clinical Pain
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• 제19권2호
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• pp.116-119
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• 2020

Cervical transforaminal epidural steroid injection (TFESI) is commonly performed to provide relief of pain caused by radiculopathy. Intra-arterial injection of particulate steroid or direct needle injury can lead to spinal artery embolism or thrombosis. Also there is a possibility of vascular spasm. To our knowledge, this is the first reported case of spinal cord infarction that occurred after TFESI with non-particulate steroid in Korea. A 47-year-old female patient underwent C7 TFESI at local pain clinic. Injected materials were dexamethasone and mepivacaine. Right after the intervention, she felt muscle weakness and decreased sensation. On physical examination, she had decreased sensation from C4 to T2 dermatome in light touch and pin-prick test. Proprioception and vibration were intact. The motor grades of upper extremities were grade 1. Cervical and thoracic spine MRI was checked. Diffusion-weighted image and apparent diffusion coefficient image showed long extension of spinal cord infarction from C2 to T1 level.

• The Korean Journal of Pain
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• 제24권1호
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• pp.53-56
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• 2011

Although postherpetic neuralgia (PHN) is a common chronic pain syndrome, the pathophysiology of this disorder is not well known and management is often very difficult. N-methyl-D-Aspartate (NMDA) receptor antagonists are known to be effective in PHN, and magnesium, a physiological blocker of NMDA receptors, is widely used to treat various chronic pain disorders. Here, we present a case of the PHN refractory to conventional treatment, which was treated successfully with transforaminal epidural injection of magnesium sulphate at the affected dermatome.

• 대한정형외과학회지
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• 제55권2호
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• pp.183-187
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• 2020

신경초 낭종은 임상적으로 흔히 관찰되기는 하나 그 중에 약 1%만이 증상을 야기한다. 특히 증상을 일으키는 경추부 신경초 낭종은 매우 드물어 5예의 문헌보고만 있을 뿐이며 치료에 대한 원칙 또한 정립되어 있지 않다. 경추부 신경병증을 호소하는 환자에서 다른 명확한 압박의 원인 없이 경추부 신경초 낭종이 발견되었을 경우에 신경초 낭종은 경추부 신경근병증의 원인으로 고려할 수 있다. 이러한 경추부 신경초 낭종은 수술적 치료 이전에 비수술적 보존적 치료를 먼저 고려할 수 있다. 저자들은 40세 여자환자에서 경구 스테로이드 복용 및 경추간공 경막외 스테로이드 주사를 통하여 증상을 일으키는 경추부 신경초 낭종의 효과적 치료를 경험한 바, 이를 문헌 고찰과 함께 살펴보고자 한다.

• Journal of Korean Neurosurgical Society
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• 제67권2호
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• pp.194-201
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• 2024

Objective : This study aimed to evaluate the clinical feasibility of the combination of ultrasound and nerve stimulator guidance in transforaminal epidural steroid injections (TESIs) to manage lumbosacral chronic radicular pain. Methods : Using the combination of nerve stimulator and ultrasound guidance, TESIs were performed in 125 segments of 78 patients who presented with chronic lumbar radicular pain. Demographic characteristics and surgical outcomes were recorded on admission, pre-procedural and post-procedural for 1-week, 1-month, 3-month, and 6-month follow-ups. The result was measured using the Numeric rating scale (NRS) and Oswestry disability index (ODI). Results : Patients who received TESIs showed significant improvements on two evaluation tools (NRS, ODI), compared to that before procedure (p<0.001). No significant complications were observed for 6 months' follow-up. Conclusion : The result suggests that a combination of ultrasound and nerve stimulator guidance in transforaminal epidural injections is safe, reliable and effective for short-term management of lumbar disc herniation. It is a promising technique and has shown good results in providing intermediate pain relief.

• The Korean Journal of Pain
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• 제27권4호
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• pp.353-359
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• 2014

Background: Epidural steroid injections are an accepted procedure for the conservative management of chronic backache caused by lumbar disc pathology. The purpose of this study was to evaluate the epidurographic findings for the midline, transforaminal and parasagittal approaches in lumbar epidural steroid injections, and correlating them with the clinical improvement. Methods: Sixty chronic lower back pain patients with unilateral radiculitis from a herniated/degenerated disc were enrolled. After screening the patients according to the exclusion criteria and randomly allocating them to 3 groups of 20 patients, fluoroscopic contrast enhanced epidural steroids were injected via midline (group 1), transforaminal (group 2) and parasagittal interlaminar (group 3) approaches at the level of the pathology. The fluoroscopic patterns of the three groups were studied and correlated with the clinical improvement measured by the VAS over the next 3 months; any incidences of complications were recorded. Results: The transforaminal group presented better results in terms of VAS reduction than the midline and parasagittal approach groups (P < 0.05). The epidurography showed a better ventral spread for both the transforaminal (P < 0.001) and the paramedian approaches (P < 0.05), as compared to the midline approach. The nerve root filling was greater in the transforaminal group (P < 0.001) than in the other two groups. The ventral spread of the contrast agent was associated with improvement in the VAS score and this difference was statistically significant in group 1 (P < 0.05), and highly significant in groups 2 and 3 (P < 0.001). In all the groups, any complications observed were transient and minor. Conclusions: The midline and paramedian approaches are technically easier and statistically comparable, but clinically less efficacious than the transforaminal approach. The incidence of ventral spread and nerve root delineation show a definite correlation with clinical improvement. However, an longer follow-up period is advisable for a better evaluation of the actual outcom.

• The Korean Journal of Pain
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• 제21권2호
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• pp.136-142
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• 2008

Background: A transforaminal epidural steroid injection (TFESI) is one of the methods for the conservative treatment of the lumbar spinal stenosis. As efforts to prolong the therapeutic duration and to predict the outcome of TFESI are very important, we analyzed factors considered to be associated with the therapeutic duration of a TFESI. Methods: Between August 2006 and March 2007, 69 patients (Group A: patients with no pain relief, Group B: patients with pain relief of less than 6 months, Group C: patients with pain relief of more than 6 months) who failed to the medical treatment were included to undertake a fluoroscopic-guided TFESI. Prior to treatment, the VAS (visual analogue scale), ODI (Oswestry disability index), BDI (Beck depression inventory), and BAI (Beck anxiety inventory) scores were determined to evaluate the degree of pain, disability, and psychological status. The VAS and ODI scores were used to assess the degree of pain relief. To identify the total duration of pain relief, regular outpatient visits for six months were conducted, and for the patients who were not able to visit the outpatient clinic regularly, outcome was assessed by telephone interviews after six months. Results: The dural sac cross-sectional area (DSCSA), ODI, pain duration, BDI, BAI, and age showed similar distribution for patients in the A, B, and C groups. Conclusions: The DSCSA, ODI, pain duration, BDI, BAI, and age were not associated with the therapeutic duration of TFESI in lumbar spinal stenosis patients.