Use of CT-guided periradicular injection for the treatment of foraminal and extraforaminal disc herniations

ABSTRACT

 

Study design: Retrospective case series. Evidence level IV.

Objectives: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option for avoiding surgery.

Methods: We carried out a retrospective evaluation of 46 consecutive patients with foraminal or extraforaminal disc herniation treated with CTGPI. CTGPI was performed only when radicular pain could not be controlled, or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years.

Results: At 1 month after injection, 41 (89%) patients experienced a decrease in radicular pain; 3 experienced no change; and 2 had received surgical treatment. At the final follow-up visit (mean, 74 months) 6 additional patients underwent surgery while 38 (83%) did not require surgery. Pain level comparison between pre-injection and last examination showed that low back pain had decreased a mean of 5 points and radicular pain diminished a mean of 7 points. Twenty-two (58%) of the 38 nonoperated patients had no pain at all and 35 patients had resumed their normal daily activities. No complications were recorded.

Conclusion: Based on these results, we consider that the use of CTGPI is a reliable alternative before surgery for patients with foraminal or extraforaminal disc herniation without severe motor deficit but with intractable radicular pain.

The authors have no conflict of interest for this study. No funding was received for research.

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EDITORIAL PERSPECTIVE

The reviewers congratulate the authors on taking on this contentious topic of managing lumbar disc herniation with nonsurgical care and openly discussing the shortcomings (retrospective, absence of comparison group, reliance on a single score only – VAS, no ODI, EQ-5D, SF-12, or others were used, and the natural course history of foraminal disc herniation remains unknown). The authors very convincingly showed a large percentage of their patients experiencing dramatic pain decrease through high-quality foraminal injections guided by CT scan imaging in the hands of seasoned interventionalists. The use of this imaging modality and the apparent quality of the injection specialists at the study site present a clear difference to the methods presented by authors of other studies, such as the classic study by Cuckler et al [1]..

The topic of epidural injections and their efficacy and efficiency has eluded conclusive answers from formal prospectively randomized trials for some time now. The dynamic nature of disc herniation in particular has been a similar source of frustration for organizers of much larger well-funded prospective trials, such as the SPORT trial with 1092 patient [2].

The number and dimensions of confounding variables continue to pose prohibitive impediments for these studies, with issues including disc pathology (size and location of disc herniation, pressure and / or tension created on neural elements), patient factors (age, neural status, pain tolerance, comorbidities, and baseline functional status to name a few) and many other factors, such as duration of symptoms, expectations, and patient preferences all playing a role in the final symptom presentation. Attempts at defining the natural course history of radiculopathy, beyond stating the obvious, have been frustrating as well; basically, most patients with radiculopathy get better on their own [3].

The role of interventions, such as discussed in the article by Gruenberg et al, remains unclear. Do they intend to (1) decrease the utilization of surgical decompression (surgery seen as failure of nonoperative care); (2) shorten the duration of the natural course history of patients with radiculopathy (treatment effect); or, (3) merely attenuate patient discomfort during the acute phase? Also, how soon upon initial presentation of a patient with radicular symptoms does one recommend injection? Right away or should one wait for some time? Then there is the question of repeated injections. How long should patients expect to have pain relief with such an injection? When and how often should one inject again? What accompanying protocol should a patient follow? Lead a normal life or pursue some form of a special regimen? This is a complex web of issues without clear metrics for some of the concerns raised, most of all the underlying question of quantifying the actual duration of the natural course history of symptomatic disc herniation, which has been described to range from a few days to weeks or even months.

Another important variable difficult to distinguish is that of surgeon threshold for procedures and the ‘treatment culture’ present in any given region or country. There are undoubtedly different expectations set by initial practitioner behavior regarding patients presenting with radiculopathy. The expectations set by practitioners and the overall healthcare culture likely influence patient behavior dramatically – setting the stage for patients requesting early surgery out of fear of neurological deterioration and with the promise of earlier return to a normal life compared with those being willing to put up with nonoperative care for radiculopathy without motor deficit even without getting an MRI scan for weeks or months [4]. The variability of physician behaviors, range of responses, and individuality of care will inevitably clash with insights gained through review of larger patient databases, such as collected in registries.

For now, this study suggests that a well-performed foraminal epidural steroid injection is a treatment option for patients with radicular symptoms. When considering future studies involving epidural steroid injections the possibility of including CT-based confirmation of periradicular needle location for patients with selected pathology certainly would seem to be a worthwhile consideration.

1. Cuckler JM, Bernini PA, Wiesel SW, et al (1985) The use of epidural steroids in the treatment of lumbar radicular pain: a prospective, randomized, doubleblind study. J Bone Joint Surg; 67-A: 63 – 66.

2. Pearson A, Lurie J, Tosteson T, et al (2011) Who should have surgery for an intervertebral disc herniation? Comparative effectiveness evidence from SPORT. Spine (Phila Pa 1976); 2011 June 15. [Epub ahead of print].

3. Casey E (2011) Natural history of radiculopathy. Phys Med Rehabil Clin N Am; 22 (1): 1 – 5. Epub 2010 Dec 3.

4. Gremeaux V, Viviez T, Bousquet P, et al (2011) How do general practitioners assess low back pain websites? Spine (Phila Pa 1976); 2011 Mar 14. [Epub ahead of print].