Support for Transforaminal Epidural
Steroid Injections
AJNR Am J Neuroradiol. 2006 May;27(5):978-82.
Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy.
Cyteval C, Fescquet N, Thomas E, Decoux E, Blotman F, Taourel P. Medical Imaging Department, Lapeyronie Hospital, Montpellier, France.
BACKGROUND AND PURPOSE: Steroid periradicular infiltration is a common nonsurgical sciatic pain treatment of inconsistent efficacy. The purpose
of this study was to identify factors for predicting the efficacy or failure of this procedure. METHODS: Two hundred twenty-nine patients with lumbar
radiculopathy were prospectively followed up at 2 weeks and 1 year after percutaneous periradicular steroid infiltration. The intensity of radicular
pain was scored on the visual analog scale (VAS). Pain relief was classified as "excellent" when the pain was completely resolved or had
diminished by 75% or more, "good" for a diminution of 50% to 74%, "fair" for a diminution of 25% to 49%, or "poor" for a diminution of less than 25%
or an increase in pain. RESULTS: The mean VAS scores were 6.5 (range, 3.1-9.5) before and 4.2 (range, 0-9.5) 2 weeks after the procedure. Pain
relief was graded as excellent in 45 patients (19.7%), good in 48 patients (21%), fair in 45 patients (19.7%), and poor in 91 patients (39.7%).
Cause of pain, conflict location, and pain intensity were not predictive factors of radicular pain relief, whereas the symptom duration before the
procedure was highly correlated with the pain relief outcome. Patients with excellent results 2 weeks after the procedure had a mean duration of
symptoms of 3.04 months (SD 3.28) versus 7.96 months (DS 9.04) in the group with poor pain relief. CONCLUSIONS: Periradicular infiltration is a
simple, safe, and effective nonsurgical procedure that should be performed quite early in the course of the illness to provide radicular pain relief,
because corticosteroid infiltration is less beneficial for patients with more chronic radicular pain.
Pain Physician. 2006 Oct;9(4):361-6.
Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations.
Schaufele MK, Hatch L, Jones W. The Emory Spine Center, Emory University School of Medicine, Atlanta, Georgia
30329, USA. michael.schaufele@emoryhealthcare.org
BACKGROUND: Epidural steroid injections are commonly used for the treatment of radicular symptoms associated with symptomatic lumbar
intervertebral disc herniations. Transforaminal epidural injections are believed to produce better clinical outcomes than interlaminar epidural
injections. OBJECTIVE: To determine a difference in short-term pain improvement and longterm surgical rates between interlaminar and
transforaminal injection techniques. DESIGN: Case Control Study. METHODS: For each technique, 20 patients were retrospectively identified
who received their first fluoroscopically guided epidural steroid injection for radicular symptoms caused by a lumbar intravertebral disc herniation
over an 18 months interval. All patients had corresponding MRI findings and failed previous non-invasive therapies. The Verbal Numerical Rating
Scale (VNRS, 0-10 scale) before the treatment, within one hour after the treatment and upon follow-up (average 17.1 days) were analyzed, along with
the need for repeat injections and surgical interventions over a 1-year follow-up interval. The patient groups were matched for symptom duration,
MRI findings and pre-injection VNRS scores. RESULTS: In the transforaminal group, there was a statistically significant improvement in the VNRS
scores from before the injection (VNRS mean 5.9) to immediately after the injection (VNRS mean 2.9, p<0.01), and upon follow-up
(VNRS mean 3.2, p<0.01, mean 18.7 days). Nine patients (45%) required 1 or 2 repeated injections, 2 patients (10%) underwent surgery. In the
interlaminar group, there was a statistically significant improvement in the VNRS scores from before the injection (VNRS mean 7.3) to immediately
after the injection (VNRS mean 3.1, p<0.01), and upon follow-up (VNRS mean 5.9, p<0.01, mean 15.6 days). Eight patients (40%) required 1 or 2
repeated injection, 5 patients (25%) underwent surgery. Fourteen patients (70%) had an improvement of 2 points or more on the VNRS scale in the
transforaminal group, compared to 9 (45%) in the interlaminar group. CONCLUSIONS: In the current study, transforaminal epidural steroid injections
for the treatment of symptomatic lumbar disc herniation resulted in better short-term pain improvement and fewer long-term surgical interventions
than interlaminar epidural steroid injection.
Pain Physician. 2002 Jul;5(3):266-70.
Effectiveness of transforaminal epidural steroid injections in low back pain: a one year experience.
Rosenberg SK, Grabinsky A, Kooser C, Boswell MV.
Anesthesia Pain Service, Department of Anesthesiology, University Hospitals of Cleveland, Cleveland, OH 44106.
Transforaminal epidural steroid injections under fluoroscopy are an alternative treatment for lower back pain with radiculopathy. We followed 82
patients with a stand-ardized telephone questionnaire at 2, 6, and 12 months after the first injection, in order to assess their effectiveness.
Ninety-two patients with radiculopathic back pain due to spinal stenosis, herniated discs, spondylolisthesis, and degenerated discs, underwent
transforaminal epidural steroid injections under fluoroscopy. Eighty-two patients were followed with a standardized telephone questionnaire. The
population was divided into four groups: Group I, previous back surgery (16%); Group II, discogenic abnormalities: herniations, bulges, or
degeneration, (42%); Group III, spinal stenosis (32%); Group IV, those without MRI (11%). Age ranged between 24 to 99 years, mean 64.5.
Forty-seven were female, 35 male. Thirteen patients (16%) underwent one procedure, 27 patients (33%) two, 37 patients (45%) three, and
five patients (6%) four, an average 2.4 procedures per patient. The pain scores for all patients improved significantly at all three time points (2, 6
and 12 months) compared to the initial mean pain score of 7.3 to mean pain scores of 3.4, 4.5 and 3.9 respectively. After one year, 36 patients did
not take any pain medications. Greater than 50% improvement after one year was seen in 23% of Group I; 59% in Group II; 35% in Group III and 67%
in Group IV. Transforaminal epidural steroid injections can offer significant pain reduction up to one year after initiation of treatment in patients with
discogenic pain and possibly in patients with spinal stenosis.
Pain Physician. 2004 Jul;7(3):311-7.
Effectiveness of transforaminal epidural steroid injections in patients with degenerative lumbar scoliotic stenosis and radiculopathy.
Cooper G, Lutz GE, Boachie-Adjei O, Lin J.
Physiatry Department Hospital for Special Surgery 550 East 70th Street New York,NY 10021.
BACKGROUND: The use of epidural steroid injections as a treatment for patients with degenerative lumbar scoliotic spinal stenosis and
radiculopathy has received sparse attention in the literature. Even though it has been reported that patients with scoliosis may respond differently
than other patient groups to conservative therapeutic interventions for low back pain and radiculopathy, patients with scoliosis have rarely, if ever,
been excluded from clinical studies of epidural steroid injections. To date, there are no studies investigating the efficacy of fluoroscopic
transforaminal epidural steroid injections as a treatment for patients with radiculopathy and radiographic evidence of degenerative lumbar scoliotic
stenosis. OBJECTIVE: To evaluate the effectiveness of fluoroscopically guided transforaminal epidural steroid injections as a conservative
treatment for patients with degenerative lumbar scoliotic stenosis and radiculopathy. DESIGN: Retrospective case series.METHODS: The study was
performed in an academic outpatient physical medicine and rehabilitation spine practice. Participants included 61 patients with radiographic
evidence of degenerative lumbar scoliotic stenosis and radiculopathy. Patients who had undergone at least one fluoroscopic-guidedtransforaminal
epidural steroid and anesthetic injection were included. MAIN OUTCOME MEASURES: Numeric Rating Scale (NRS) for worst pain experienced, North
American Spine Society (NASS) satisfaction scale, amount of pain medication used, and adapted Stucki questionnaire to assess function and pain
status. RESULTS: We obtained follow-up on 52 (85.2%) of 61 included patients. We defined a successful outcome as a patient who was both
satisfied with his or her results and experienced at least a 2-points improvement in NRS, Summary Pain, and Summary Function scores. Using
these criteria for success, 59.6% of our patients had a successful outcome at one week post-injection, 55.8% at one month post-injection, 37.2% at
one year post-injection, and 27.3% had a successful outcome at two years post-injection (p < 0.01). CONCLUSION: Fluoroscopic transforaminal
epidural steroid injections appear to be an effective nonsurgical treatment option for patients with degenerative lumbar scoliotic stenosis and
radiculopathy and should be considered before surgical intervention.
Korean J Radiol. 2006 Apr-Jun;7(2):139-44.
Transforaminal epidural steroid injection for lumbosacral radiculopathy: preganglionic versus conventional approach.
Lee JW, Kim SH, Choi JY, Yeom JS, Kim KJ, Chung SK, Kim HJ, Kim C, Kwack KS, Kwon JW, Moon SG, Jun WS, Kang HS.
Department of Radiology, Seoul National University Bundang Hospital, Gyeongi-do, Korea.
OBJECTIVE: The present study was undertaken to evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) with using a
preganglionic approach for treating lumbar radiculopathy when the nerve root compression was located at the level of the supra-adjacent
intervertebral disc. MATERIALS AND METHODS: The medical records of the patients who received conventional TFESI at our department from June
2003 to May 2004 were retrospectively reviewed. TFESI was performed in a total of 13 cases at the level of the exiting nerve root, in
which the nerve root compression was at the level of the supra-adjacent intervertebral disc (the conventional TFESI group). Since June 2004, we
have performed TFESI with using a preganglionic approach at the level of the supra-adjacent intervertebral disc (for example, at the neural foramen
of L4-5 for the L5 nerve root) if the nerve root compression was at the level of the supra-adjacent intervertebral disc. Using the inclusion criteria
described above, 20 of these patients were also consecutively enrolled in our study (the preganglionic TFESI group). The treatment outcome was
assessed using a 5-point patient satisfaction scale and by using a VAS (visual assessment scale). A successful outcome required a patient
satisfaction scale score of 3 (very good) or 4 (excellent), and a reduction on the VAS score of > 50% two weeks after performing TFESI. Logistic
regression analysis was also performed. RESULTS: Of the 13 patients in the conventional TFESI group, nine showed satisfactory improvement two
weeks after TFESI (69.2%). However, in the preganglionic TFESI group, 18 of the 20 patients (90%) showed satisfactory improvement. The
difference between the two approaches in terms of TFESI effectiveness was of borderline significance (p = 0.056; odds ratio: 10.483). CONCLUSION:
We conclude that preganglionic TFESI has the better therapeutic effect on radiculopathy caused by nerve root compression at the level of the
supra-adjacent disc than does conventional TFESI, and the difference between the two treatments had borderline statistical significance.
Chang Gung Med J. 2006 Jan-Feb;29(1):93-9.
Transforaminal epidural steroid injection for discectomy candidates: an outcome study with a minimum of two-year follow-up.
Yang SC, Fu TS, Lai PL, Niu CC, Chen LH, Chen WJ. Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taipei, ROC.
BACKGROUND: The efficacy of epidural steroid injection for sciatica due to herniated disc is controversial. This study evaluates the therapeutic
effect of an alternative technique that uses a modified approach of epidural steroid injection for the above mentioned disease. The aim was to
determine whether this procedure can reduce the need of surgery among discectomy candidates. METHODS: Twenty-one eligible patients who had
suffered from sciatica with unilateral symptoms for 2 to 24 months received injections of betamethasone in combination with xylocaine. The
treatment outcome was evaluated by direct questioning and examination using the JOA score (the criteria for low back pain syndrome of Japanese
Orthopaedic Association) before the procedure and at the final follow-up visit. The final analysis comprised 19 patients with a minimum of 24-month
follow-up. RESULTS: The overall JOA score increased significantly from 14.26 +/- 3.25 before injection to 23.38 +/- 4.46 after injection showing
improvement. In terms of subcategories, the JOA score for sciatica increased significantly from 0.69 +/- 0.48 before infection to 2.13 +/- 0.72 after
injection and the JOA score for daily activity increased significantly from 7.44 +/- 2.16 before injection to 12.19 +/- 2.23 after injection). In the end,
three treated patients received surgical decompression for intractable recurrent pain. CONCLUSIONS: Transforaminal epidural steroid injection is a
relatively simple, effective and low-risk alternative to surgical decompression for the treatment of lumbar disc herniation in selected cases. The
procedure significantly alleviates the severity of sciatica due to a herniated disc and improves the patient's daily activity; this reduces the need for
surgical decompression.
Arch Phys Med Rehabil. 2005 Jul;86(7):1477-83.
A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy.
DePalma MJ, Bhargava A, Slipman CW. Penn Spine Center and Department of Physical Medicine and Rehabilitation, Hospital of the University of
Pennsylvania, Philadelphia, PA 19104, USA.
OBJECTIVE: To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root
blocks (SNRBs) to treat lumbosacral radiculopathy. DATA SOURCES: MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database.
Databases were searched from inception through 2003. STUDY SELECTION: A database search was conducted by using the following key words:
prospective , transforaminal and foraminal epidural steroid injections , selective nerve root block and injection, and periradicular and nerve root
injection . We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with
fluoroscopically guided nerve root or transforaminal epidural injections. DATA EXTRACTION: Data were compiled for each of the following
categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized,
documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were
abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and
Policy Research. DATA SYNTHESIS: We selected 6 articles for review. Our analysis identified a single article as the highest quality study
addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded
because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of
these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking.
CONCLUSIONS: The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in
treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar
radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to
provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.
Acta Neurochir (Wien). 2005 Oct;147(10):1065-70; discussion 1070. Epub 2005 Jun 9.
Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study.
Kolstad F, Leivseth G, Nygaard OP. National Centre of Spinal Disorders, Norwegian University of Science and Technology, University Hospital of
Trondheim, Trondheim, Norway. Frode.Kolstad@medisin.ntnu.no
BACKGROUND: The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc
surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc
herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk
of complications.Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes
radicular pain, and therefore steroids placed locally should relieve symptoms. METHODS: During a 12-month period, 21 secondary referral patients
with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was
demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval,
while waiting for operative treatment.The pain intensity (VAS), Odom's criteria and operative indications were registered at 6 weeks and 4 months.
FINDINGS: After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically
significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative
requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those
responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as
positively as those with disc herniation. INTERPRETATION: This prospective cohort study indicates a reduction in the need for operative treatment
due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine
transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.
J Radiol. 2004 Nov;85(11):1937-41.
[Fluoroscopy guided L5-S1 transforaminal injection as a treatement for s1 radiculopathy] [Article in French]
Michel JL, Lemaire S, Bourbon H, Reynier C, Lhoste A, Soubrier S, Dubost JJ, Ristori JM.
Service de radiologie A, Hopital Gabriel-Montpied, Clermont-Ferrand-Cedex, France. jlmichel@chu-clermontferrand.fr
OBJECTIVE: To assess the efficacy of fluoroscopy guided L5-S1 transforaminal steroid injections for the treatment of S1 radiculopathy secondary to
intervertebral disk disorder. METHOD: 41 patients were included: prospective study (20 patients) and retrospective study (21 patients). All patients
suffered from S1 radiculopathy secondary to nerve root compression by intervertebral disk material, as demonstrated by lumbar spine CT. The
patients underwent 2 fluoroscopy guided L5-S1 transforaminal injections of steroid (Hydrocotancyl 125 mg), at 8 days interval. RESULTS: 60% of
patients showed significant improvement of their painful radiculopathy at day 8 (n:41), 60-67% at day 30 (n:41) and 67% at day 90 (n:18).
CONCLUSION: Fluoroscopy guided L5-S1 transforaminal injection showed good efficacy in the treatment of S1 radiculopathy.
Arch Phys Med Rehabil. 2004 Mar;85(3):479-84.
Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study.
Delport EG, Cucuzzella AR, Marley JK, Pruitt CM, Fisher JR. Christiana Spine Center, Newark, DE, USA.
OBJECTIVE: To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients
who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS). DESIGN: Retrospective review conducted using a
standard set of questions asked over the telephone, 6 to 36 months after the patient received an ESI. SETTING: An outpatient spine center.
PARTICIPANTS: One hundred forty patients at or over the age of 55 years diagnosed with LSS who received ESI(s). INTERVENTION: Transforaminal
or caudal fluoroscopically guided ESIs with 60 to 100mg of triamcinalone in combination with local anesthetic or normal saline.Main outcome
measures Duration and amount of pain relief, change in functional status, patient satisfaction, and surgical rate, assessed by a 5-item questionnaire.
RESULTS: Of the 140 participants, 32% reported more than 2 months of pain relief, 39% reported less than 2 months of pain relief, and 29% reported
no relief from the injection(s). Twenty percent subsequently had surgery. Fifty-three percent reported improvement in their functional abilities.
Seventy-four percent where at least somewhat satisfied with ESI as a form of treatment. CONCLUSIONS: ESI is a reasonable treatment for LSS,
providing one third of our patient population with sustained relief and more than half with sustained improvement in function.
Spine. 2002 Jan 1;27(1):11-6.
Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study.
Vad VB, Bhat AL, Lutz GE, Cammisa F. The Hospital for Special Surgery, New York, New York 10021, USA. vadv@hss.edu
STUDY DESIGN: A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching
hospital was conducted. OBJECTIVES: To compare transforaminal epidural steroid injections with saline trigger-point injections used in the
treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. SUMMARY OF BACKGROUND DATA: Epidural steroid injections
have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no
controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated
nucleus pulposus. METHODS: Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline
trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very
good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of
finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome
required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater
than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21
months). RESULTS: After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success
rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). CONCLUSION: Fluoroscopically guided transforaminal
injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.
Swiss Med Wkly. 2001 Feb 10;131(5-6):75-80.
Therapeutic efficacy of selective nerve root blocks in the treatment of lumbar radicular leg pain.
Narozny M, Zanetti M, Boos N.
Spinal Surgery, Orthopaedic University Hospital Balgrist, Zurich, Switzerland.
The objective of this study was to investigate the clinical effectiveness of nerve root blocks (i.e., periradicular injection of bupivacaine and
triamcinolone) for lumbar monoradiculopathy in patients with a mild neurological deficit. We have retrospectively analysed 30 patients (29-82 years)
with a minor sensory/motor deficit and an unequivocal MRI finding (20 disc herniations, 10 foraminal stenoses) treated with a selective nerve root
block. Based on the clinical and imaging findings, surgery (decompression of the nerve root) was justifiable in all cases. Twenty-six patients (87%)
had rapid (1-4 days) and substantial regression of pain, five required a repeat injection. 60% of the patients with disc herniation or foraminal
stenosis had permanent resolution of pain, so that an operation was avoided over an average of 16 months (6-23 months) follow-up. Nerve root
blocks are very effective in the non-operative treatment of minor monoradiculopathy and should be recommended as the initial treatment of choice
for this condition.
Radiology. 2001 Mar;218(3):886-92.
Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection.
Vallee JN, Feydy A, Carlier RY, Mutschler C, Mompoint D, Vallee CA. Department of Radiology, Raymond Poincare Teaching Hospital, University of
Paris 5, 104 Blvd Raymond Poincare, 92380 Garches, France.
Thirty-two patients underwent periradicular corticosteroid injections with a lateral percutaneous approach under fluoroscopic guidance, to treat 34
foci of chronic cervical radiculopathy unresponsive to medical treatment alone. The mean evolutionary trends for radicular and neck pain relief
were significant at 14 days (P <.001) and at 6 months (P <.001). The procedure did not produce any complications.
Radiology. 2001 Mar;218(3):886-92.
Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection.
Vallee JN, Feydy A, Carlier RY, Mutschler C, Mompoint D, Vallee CA. Department of Radiology, Raymond Poincare Teaching Hospital, University of
Paris 5, 104 Blvd Raymond Poincare, 92380 Garches, France.
Thirty-two patients underwent periradicular corticosteroid injections with a lateral percutaneous approach under fluoroscopic guidance, to treat 34
foci of chronic cervical radiculopathy unresponsive to medical treatment alone. The mean evolutionary trends for radicular and neck pain relief
were significant at 14 days (P <.001) and at 6 months (P <.001). The procedure did not produce any complications.
Steroid Injections
AJNR Am J Neuroradiol. 2006 May;27(5):978-82.
Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy.
Cyteval C, Fescquet N, Thomas E, Decoux E, Blotman F, Taourel P. Medical Imaging Department, Lapeyronie Hospital, Montpellier, France.
BACKGROUND AND PURPOSE: Steroid periradicular infiltration is a common nonsurgical sciatic pain treatment of inconsistent efficacy. The purpose
of this study was to identify factors for predicting the efficacy or failure of this procedure. METHODS: Two hundred twenty-nine patients with lumbar
radiculopathy were prospectively followed up at 2 weeks and 1 year after percutaneous periradicular steroid infiltration. The intensity of radicular
pain was scored on the visual analog scale (VAS). Pain relief was classified as "excellent" when the pain was completely resolved or had
diminished by 75% or more, "good" for a diminution of 50% to 74%, "fair" for a diminution of 25% to 49%, or "poor" for a diminution of less than 25%
or an increase in pain. RESULTS: The mean VAS scores were 6.5 (range, 3.1-9.5) before and 4.2 (range, 0-9.5) 2 weeks after the procedure. Pain
relief was graded as excellent in 45 patients (19.7%), good in 48 patients (21%), fair in 45 patients (19.7%), and poor in 91 patients (39.7%).
Cause of pain, conflict location, and pain intensity were not predictive factors of radicular pain relief, whereas the symptom duration before the
procedure was highly correlated with the pain relief outcome. Patients with excellent results 2 weeks after the procedure had a mean duration of
symptoms of 3.04 months (SD 3.28) versus 7.96 months (DS 9.04) in the group with poor pain relief. CONCLUSIONS: Periradicular infiltration is a
simple, safe, and effective nonsurgical procedure that should be performed quite early in the course of the illness to provide radicular pain relief,
because corticosteroid infiltration is less beneficial for patients with more chronic radicular pain.
Pain Physician. 2006 Oct;9(4):361-6.
Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations.
Schaufele MK, Hatch L, Jones W. The Emory Spine Center, Emory University School of Medicine, Atlanta, Georgia
30329, USA. michael.schaufele@emoryhealthcare.org
BACKGROUND: Epidural steroid injections are commonly used for the treatment of radicular symptoms associated with symptomatic lumbar
intervertebral disc herniations. Transforaminal epidural injections are believed to produce better clinical outcomes than interlaminar epidural
injections. OBJECTIVE: To determine a difference in short-term pain improvement and longterm surgical rates between interlaminar and
transforaminal injection techniques. DESIGN: Case Control Study. METHODS: For each technique, 20 patients were retrospectively identified
who received their first fluoroscopically guided epidural steroid injection for radicular symptoms caused by a lumbar intravertebral disc herniation
over an 18 months interval. All patients had corresponding MRI findings and failed previous non-invasive therapies. The Verbal Numerical Rating
Scale (VNRS, 0-10 scale) before the treatment, within one hour after the treatment and upon follow-up (average 17.1 days) were analyzed, along with
the need for repeat injections and surgical interventions over a 1-year follow-up interval. The patient groups were matched for symptom duration,
MRI findings and pre-injection VNRS scores. RESULTS: In the transforaminal group, there was a statistically significant improvement in the VNRS
scores from before the injection (VNRS mean 5.9) to immediately after the injection (VNRS mean 2.9, p<0.01), and upon follow-up
(VNRS mean 3.2, p<0.01, mean 18.7 days). Nine patients (45%) required 1 or 2 repeated injections, 2 patients (10%) underwent surgery. In the
interlaminar group, there was a statistically significant improvement in the VNRS scores from before the injection (VNRS mean 7.3) to immediately
after the injection (VNRS mean 3.1, p<0.01), and upon follow-up (VNRS mean 5.9, p<0.01, mean 15.6 days). Eight patients (40%) required 1 or 2
repeated injection, 5 patients (25%) underwent surgery. Fourteen patients (70%) had an improvement of 2 points or more on the VNRS scale in the
transforaminal group, compared to 9 (45%) in the interlaminar group. CONCLUSIONS: In the current study, transforaminal epidural steroid injections
for the treatment of symptomatic lumbar disc herniation resulted in better short-term pain improvement and fewer long-term surgical interventions
than interlaminar epidural steroid injection.
Pain Physician. 2002 Jul;5(3):266-70.
Effectiveness of transforaminal epidural steroid injections in low back pain: a one year experience.
Rosenberg SK, Grabinsky A, Kooser C, Boswell MV.
Anesthesia Pain Service, Department of Anesthesiology, University Hospitals of Cleveland, Cleveland, OH 44106.
Transforaminal epidural steroid injections under fluoroscopy are an alternative treatment for lower back pain with radiculopathy. We followed 82
patients with a stand-ardized telephone questionnaire at 2, 6, and 12 months after the first injection, in order to assess their effectiveness.
Ninety-two patients with radiculopathic back pain due to spinal stenosis, herniated discs, spondylolisthesis, and degenerated discs, underwent
transforaminal epidural steroid injections under fluoroscopy. Eighty-two patients were followed with a standardized telephone questionnaire. The
population was divided into four groups: Group I, previous back surgery (16%); Group II, discogenic abnormalities: herniations, bulges, or
degeneration, (42%); Group III, spinal stenosis (32%); Group IV, those without MRI (11%). Age ranged between 24 to 99 years, mean 64.5.
Forty-seven were female, 35 male. Thirteen patients (16%) underwent one procedure, 27 patients (33%) two, 37 patients (45%) three, and
five patients (6%) four, an average 2.4 procedures per patient. The pain scores for all patients improved significantly at all three time points (2, 6
and 12 months) compared to the initial mean pain score of 7.3 to mean pain scores of 3.4, 4.5 and 3.9 respectively. After one year, 36 patients did
not take any pain medications. Greater than 50% improvement after one year was seen in 23% of Group I; 59% in Group II; 35% in Group III and 67%
in Group IV. Transforaminal epidural steroid injections can offer significant pain reduction up to one year after initiation of treatment in patients with
discogenic pain and possibly in patients with spinal stenosis.
Pain Physician. 2004 Jul;7(3):311-7.
Effectiveness of transforaminal epidural steroid injections in patients with degenerative lumbar scoliotic stenosis and radiculopathy.
Cooper G, Lutz GE, Boachie-Adjei O, Lin J.
Physiatry Department Hospital for Special Surgery 550 East 70th Street New York,NY 10021.
BACKGROUND: The use of epidural steroid injections as a treatment for patients with degenerative lumbar scoliotic spinal stenosis and
radiculopathy has received sparse attention in the literature. Even though it has been reported that patients with scoliosis may respond differently
than other patient groups to conservative therapeutic interventions for low back pain and radiculopathy, patients with scoliosis have rarely, if ever,
been excluded from clinical studies of epidural steroid injections. To date, there are no studies investigating the efficacy of fluoroscopic
transforaminal epidural steroid injections as a treatment for patients with radiculopathy and radiographic evidence of degenerative lumbar scoliotic
stenosis. OBJECTIVE: To evaluate the effectiveness of fluoroscopically guided transforaminal epidural steroid injections as a conservative
treatment for patients with degenerative lumbar scoliotic stenosis and radiculopathy. DESIGN: Retrospective case series.METHODS: The study was
performed in an academic outpatient physical medicine and rehabilitation spine practice. Participants included 61 patients with radiographic
evidence of degenerative lumbar scoliotic stenosis and radiculopathy. Patients who had undergone at least one fluoroscopic-guidedtransforaminal
epidural steroid and anesthetic injection were included. MAIN OUTCOME MEASURES: Numeric Rating Scale (NRS) for worst pain experienced, North
American Spine Society (NASS) satisfaction scale, amount of pain medication used, and adapted Stucki questionnaire to assess function and pain
status. RESULTS: We obtained follow-up on 52 (85.2%) of 61 included patients. We defined a successful outcome as a patient who was both
satisfied with his or her results and experienced at least a 2-points improvement in NRS, Summary Pain, and Summary Function scores. Using
these criteria for success, 59.6% of our patients had a successful outcome at one week post-injection, 55.8% at one month post-injection, 37.2% at
one year post-injection, and 27.3% had a successful outcome at two years post-injection (p < 0.01). CONCLUSION: Fluoroscopic transforaminal
epidural steroid injections appear to be an effective nonsurgical treatment option for patients with degenerative lumbar scoliotic stenosis and
radiculopathy and should be considered before surgical intervention.
Korean J Radiol. 2006 Apr-Jun;7(2):139-44.
Transforaminal epidural steroid injection for lumbosacral radiculopathy: preganglionic versus conventional approach.
Lee JW, Kim SH, Choi JY, Yeom JS, Kim KJ, Chung SK, Kim HJ, Kim C, Kwack KS, Kwon JW, Moon SG, Jun WS, Kang HS.
Department of Radiology, Seoul National University Bundang Hospital, Gyeongi-do, Korea.
OBJECTIVE: The present study was undertaken to evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) with using a
preganglionic approach for treating lumbar radiculopathy when the nerve root compression was located at the level of the supra-adjacent
intervertebral disc. MATERIALS AND METHODS: The medical records of the patients who received conventional TFESI at our department from June
2003 to May 2004 were retrospectively reviewed. TFESI was performed in a total of 13 cases at the level of the exiting nerve root, in
which the nerve root compression was at the level of the supra-adjacent intervertebral disc (the conventional TFESI group). Since June 2004, we
have performed TFESI with using a preganglionic approach at the level of the supra-adjacent intervertebral disc (for example, at the neural foramen
of L4-5 for the L5 nerve root) if the nerve root compression was at the level of the supra-adjacent intervertebral disc. Using the inclusion criteria
described above, 20 of these patients were also consecutively enrolled in our study (the preganglionic TFESI group). The treatment outcome was
assessed using a 5-point patient satisfaction scale and by using a VAS (visual assessment scale). A successful outcome required a patient
satisfaction scale score of 3 (very good) or 4 (excellent), and a reduction on the VAS score of > 50% two weeks after performing TFESI. Logistic
regression analysis was also performed. RESULTS: Of the 13 patients in the conventional TFESI group, nine showed satisfactory improvement two
weeks after TFESI (69.2%). However, in the preganglionic TFESI group, 18 of the 20 patients (90%) showed satisfactory improvement. The
difference between the two approaches in terms of TFESI effectiveness was of borderline significance (p = 0.056; odds ratio: 10.483). CONCLUSION:
We conclude that preganglionic TFESI has the better therapeutic effect on radiculopathy caused by nerve root compression at the level of the
supra-adjacent disc than does conventional TFESI, and the difference between the two treatments had borderline statistical significance.
Chang Gung Med J. 2006 Jan-Feb;29(1):93-9.
Transforaminal epidural steroid injection for discectomy candidates: an outcome study with a minimum of two-year follow-up.
Yang SC, Fu TS, Lai PL, Niu CC, Chen LH, Chen WJ. Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taipei, ROC.
BACKGROUND: The efficacy of epidural steroid injection for sciatica due to herniated disc is controversial. This study evaluates the therapeutic
effect of an alternative technique that uses a modified approach of epidural steroid injection for the above mentioned disease. The aim was to
determine whether this procedure can reduce the need of surgery among discectomy candidates. METHODS: Twenty-one eligible patients who had
suffered from sciatica with unilateral symptoms for 2 to 24 months received injections of betamethasone in combination with xylocaine. The
treatment outcome was evaluated by direct questioning and examination using the JOA score (the criteria for low back pain syndrome of Japanese
Orthopaedic Association) before the procedure and at the final follow-up visit. The final analysis comprised 19 patients with a minimum of 24-month
follow-up. RESULTS: The overall JOA score increased significantly from 14.26 +/- 3.25 before injection to 23.38 +/- 4.46 after injection showing
improvement. In terms of subcategories, the JOA score for sciatica increased significantly from 0.69 +/- 0.48 before infection to 2.13 +/- 0.72 after
injection and the JOA score for daily activity increased significantly from 7.44 +/- 2.16 before injection to 12.19 +/- 2.23 after injection). In the end,
three treated patients received surgical decompression for intractable recurrent pain. CONCLUSIONS: Transforaminal epidural steroid injection is a
relatively simple, effective and low-risk alternative to surgical decompression for the treatment of lumbar disc herniation in selected cases. The
procedure significantly alleviates the severity of sciatica due to a herniated disc and improves the patient's daily activity; this reduces the need for
surgical decompression.
Arch Phys Med Rehabil. 2005 Jul;86(7):1477-83.
A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy.
DePalma MJ, Bhargava A, Slipman CW. Penn Spine Center and Department of Physical Medicine and Rehabilitation, Hospital of the University of
Pennsylvania, Philadelphia, PA 19104, USA.
OBJECTIVE: To critically review the best available trials of the utility of transforaminal epidural steroid injections (TFESIs) or selective nerve root
blocks (SNRBs) to treat lumbosacral radiculopathy. DATA SOURCES: MEDLINE (PubMed, Ovid, MDConsult), EMBASE, and the Cochrane database.
Databases were searched from inception through 2003. STUDY SELECTION: A database search was conducted by using the following key words:
prospective , transforaminal and foraminal epidural steroid injections , selective nerve root block and injection, and periradicular and nerve root
injection . We included English-language, prospective, randomized studies of patients with lower-limb radicular symptoms treated with
fluoroscopically guided nerve root or transforaminal epidural injections. DATA EXTRACTION: Data were compiled for each of the following
categories: inclusion criteria, randomization protocol, total number of subjects enrolled initially and at final analysis, statistical analysis utilized,
documentation of technique, outcome measures, follow-up intervals and results (positive or negative), and reported complications. These data were
abstracted by 1 reviewer and reviewed by a second. Study quality was assessed with the system developed by the Agency for Health Care and
Policy Research. DATA SYNTHESIS: We selected 6 articles for review. Our analysis identified a single article as the highest quality study
addressing the appropriate use of TFESIs or therapeutic SNRBs. Coupled with the evidence provided by 4 other articles (1 article was excluded
because its patients were not truly randomized), our review of the evidence for TFESIs found level III (moderate) evidence in support of
these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking.
CONCLUSIONS: The evidence for TFESIs reveals level III (moderate) evidence in support of these minimally invasive and safe procedures in
treating painful lumbar radicular symptoms. Current studies support use of TFESIs as a safe and minimally invasive adjunct treatment for lumbar
radicular symptoms. However, more prospective, randomized, placebo-controlled studies using sham procedures are needed to
provide conclusive evidence for the efficacy of TFESIs in treating lumbar radicular symptoms.
Acta Neurochir (Wien). 2005 Oct;147(10):1065-70; discussion 1070. Epub 2005 Jun 9.
Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study.
Kolstad F, Leivseth G, Nygaard OP. National Centre of Spinal Disorders, Norwegian University of Science and Technology, University Hospital of
Trondheim, Trondheim, Norway. Frode.Kolstad@medisin.ntnu.no
BACKGROUND: The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc
surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc
herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk
of complications.Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes
radicular pain, and therefore steroids placed locally should relieve symptoms. METHODS: During a 12-month period, 21 secondary referral patients
with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was
demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval,
while waiting for operative treatment.The pain intensity (VAS), Odom's criteria and operative indications were registered at 6 weeks and 4 months.
FINDINGS: After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically
significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative
requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those
responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as
positively as those with disc herniation. INTERPRETATION: This prospective cohort study indicates a reduction in the need for operative treatment
due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine
transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.
J Radiol. 2004 Nov;85(11):1937-41.
[Fluoroscopy guided L5-S1 transforaminal injection as a treatement for s1 radiculopathy] [Article in French]
Michel JL, Lemaire S, Bourbon H, Reynier C, Lhoste A, Soubrier S, Dubost JJ, Ristori JM.
Service de radiologie A, Hopital Gabriel-Montpied, Clermont-Ferrand-Cedex, France. jlmichel@chu-clermontferrand.fr
OBJECTIVE: To assess the efficacy of fluoroscopy guided L5-S1 transforaminal steroid injections for the treatment of S1 radiculopathy secondary to
intervertebral disk disorder. METHOD: 41 patients were included: prospective study (20 patients) and retrospective study (21 patients). All patients
suffered from S1 radiculopathy secondary to nerve root compression by intervertebral disk material, as demonstrated by lumbar spine CT. The
patients underwent 2 fluoroscopy guided L5-S1 transforaminal injections of steroid (Hydrocotancyl 125 mg), at 8 days interval. RESULTS: 60% of
patients showed significant improvement of their painful radiculopathy at day 8 (n:41), 60-67% at day 30 (n:41) and 67% at day 90 (n:18).
CONCLUSION: Fluoroscopy guided L5-S1 transforaminal injection showed good efficacy in the treatment of S1 radiculopathy.
Arch Phys Med Rehabil. 2004 Mar;85(3):479-84.
Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study.
Delport EG, Cucuzzella AR, Marley JK, Pruitt CM, Fisher JR. Christiana Spine Center, Newark, DE, USA.
OBJECTIVE: To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients
who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS). DESIGN: Retrospective review conducted using a
standard set of questions asked over the telephone, 6 to 36 months after the patient received an ESI. SETTING: An outpatient spine center.
PARTICIPANTS: One hundred forty patients at or over the age of 55 years diagnosed with LSS who received ESI(s). INTERVENTION: Transforaminal
or caudal fluoroscopically guided ESIs with 60 to 100mg of triamcinalone in combination with local anesthetic or normal saline.Main outcome
measures Duration and amount of pain relief, change in functional status, patient satisfaction, and surgical rate, assessed by a 5-item questionnaire.
RESULTS: Of the 140 participants, 32% reported more than 2 months of pain relief, 39% reported less than 2 months of pain relief, and 29% reported
no relief from the injection(s). Twenty percent subsequently had surgery. Fifty-three percent reported improvement in their functional abilities.
Seventy-four percent where at least somewhat satisfied with ESI as a form of treatment. CONCLUSIONS: ESI is a reasonable treatment for LSS,
providing one third of our patient population with sustained relief and more than half with sustained improvement in function.
Spine. 2002 Jan 1;27(1):11-6.
Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study.
Vad VB, Bhat AL, Lutz GE, Cammisa F. The Hospital for Special Surgery, New York, New York 10021, USA. vadv@hss.edu
STUDY DESIGN: A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching
hospital was conducted. OBJECTIVES: To compare transforaminal epidural steroid injections with saline trigger-point injections used in the
treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. SUMMARY OF BACKGROUND DATA: Epidural steroid injections
have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no
controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated
nucleus pulposus. METHODS: Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline
trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very
good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of
finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome
required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater
than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21
months). RESULTS: After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success
rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). CONCLUSION: Fluoroscopically guided transforaminal
injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus.
Swiss Med Wkly. 2001 Feb 10;131(5-6):75-80.
Therapeutic efficacy of selective nerve root blocks in the treatment of lumbar radicular leg pain.
Narozny M, Zanetti M, Boos N.
Spinal Surgery, Orthopaedic University Hospital Balgrist, Zurich, Switzerland.
The objective of this study was to investigate the clinical effectiveness of nerve root blocks (i.e., periradicular injection of bupivacaine and
triamcinolone) for lumbar monoradiculopathy in patients with a mild neurological deficit. We have retrospectively analysed 30 patients (29-82 years)
with a minor sensory/motor deficit and an unequivocal MRI finding (20 disc herniations, 10 foraminal stenoses) treated with a selective nerve root
block. Based on the clinical and imaging findings, surgery (decompression of the nerve root) was justifiable in all cases. Twenty-six patients (87%)
had rapid (1-4 days) and substantial regression of pain, five required a repeat injection. 60% of the patients with disc herniation or foraminal
stenosis had permanent resolution of pain, so that an operation was avoided over an average of 16 months (6-23 months) follow-up. Nerve root
blocks are very effective in the non-operative treatment of minor monoradiculopathy and should be recommended as the initial treatment of choice
for this condition.
Radiology. 2001 Mar;218(3):886-92.
Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection.
Vallee JN, Feydy A, Carlier RY, Mutschler C, Mompoint D, Vallee CA. Department of Radiology, Raymond Poincare Teaching Hospital, University of
Paris 5, 104 Blvd Raymond Poincare, 92380 Garches, France.
Thirty-two patients underwent periradicular corticosteroid injections with a lateral percutaneous approach under fluoroscopic guidance, to treat 34
foci of chronic cervical radiculopathy unresponsive to medical treatment alone. The mean evolutionary trends for radicular and neck pain relief
were significant at 14 days (P <.001) and at 6 months (P <.001). The procedure did not produce any complications.
Radiology. 2001 Mar;218(3):886-92.
Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection.
Vallee JN, Feydy A, Carlier RY, Mutschler C, Mompoint D, Vallee CA. Department of Radiology, Raymond Poincare Teaching Hospital, University of
Paris 5, 104 Blvd Raymond Poincare, 92380 Garches, France.
Thirty-two patients underwent periradicular corticosteroid injections with a lateral percutaneous approach under fluoroscopic guidance, to treat 34
foci of chronic cervical radiculopathy unresponsive to medical treatment alone. The mean evolutionary trends for radicular and neck pain relief
were significant at 14 days (P <.001) and at 6 months (P <.001). The procedure did not produce any complications.
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