A comparative evaluation of kambin’s triangle approach versus safe triangle approach for lumbar transforaminal epidural injection in patients with lumbar radiculopathy - A prospective, randomized, double blind study

Background: Epidural injection of steroid and local anaesthetic is a common modality for management of radicular pain. Transforaminal approach is preferred for epidural injection in case of radiculopathy. Aims and Objectives: To compare the effect of the Kambin’s triangle and subpedicular approaches of transforaminal epidural injection (TFEI) in patients of lumbar radiculopathy. Materials and Methods: Forty patients with lumbar radicular pain were enrolled and randomly assigned to each group (Group K for Kambin’s triangle approach and Group S for subpedicular approach). All procedures were performed under fluroscopic guidance. The frequency of complications during the procedure and the effect of TFEI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual Analog scale (VAS). Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors and the therapeutic effect. Result: VAS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups. There were no statistical differences in changes of VAS between these two groups. Spinal nerve pricking occurred in one case of the subpedicular and in none of the cases of the Kambin’s triangle approach (p<0.05). Conclusion: Kambin’s triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages (i.e., less spinal nerve pricking during procedure). So, Kambin’s triangle approach may be an alternative method for TFEI in cases where needle tip positioning in the anterior epidural space is difficult.

Chemical meningitis after cervical transforaminal epidural steroid injection: a case report

We herein report a case of chemical meningitis that developed after cervical transforaminal steroid injection. A 49-year-old man presented with symptoms of meningitis (severe headache and neck stiffness) after cervical transforaminal steroid injection at the right C5–6 level. The injection solution was a mixture of lidocaine (0.3 mL), hyaluronidase (1 mL), placenta hydrolysate (2 mL), and normal saline (1 mL). The patient developed symptoms of meningitis 2.5 hours after the cervical epidural injection. Cerebrospinal fluid (CSF) analysis was performed 1 day after the injection, and the results showed an elevated white blood cell count at 7106 cells/µL. The patient’s CSF analysis findings and symptoms did not differ from those of bacterial meningitis. However, considering that his symptoms developed 2.5 hours after the epidural injection, we believe that the patient developed chemical meningitis; therefore, he was symptomatically treated with an analgesic. Three days after the cervical transforaminal epidural injection, the patient experienced complete relief from the headache and neck stiffness. A Gram stain of the CSF revealed no organisms. Hence, the diagnosis of chemical meningitis was confirmed. Clinicians should be knowledgeable about the risk of this complication.

Transforaminal Epidural Injection of Dexamethasone vs Methylprednisolone in Reducing Low Back Pain and Disability in Prolapsed Lumbar Intervertebral Disc in Manipur, India: A RCT

Introduction: Treatment for Low Back Pain (LBP) due to Prolapsed Intervertebral Disc (PIVD) includes conservative management, Epidural Steroid Injection (ESI), and surgery. Transforaminal Epidural Steroid Injection (TFESI) is a more recently described approach. All corticosteroid preparations used for TFESI are particulate except dexamethasone and betamethasone sodium phosphate. But while comparing methylprednisolone with dexamethasone, the latter has more potent anti-inflammatory action with least likelihood of causing embolic events and is also less expensive. Aim: To compare the efficacy of transforaminal epidural injection of dexamethasone and methylprednisolone in reducing LBP and disability in prolapsed lumbar intervertebral disc amongst the indigenous population of Manipur, India. Materials and Methods: This was a randomised controlled study on 80 patients with PIVD attending Outpatient Department (OPD) at physical medicine and rehabilitation was conducted from September 2016 to August 2018. A single dose of lumbar TFESI with dexamethasone in the study group and methylprednisolone in the control were given under C-arm guidance. The outcome variables Visual Analog Scale (VAS) for pain and Oswestry Disability Index (ODI) for function were measured at one week, one month and six months. Statistical tests like t-test, Chi-square test were used for intra group and inter group analysis. Results: In the total sample of 80 patients, 40 (15 males and 25 females, mean age: 38.28±8.55 years) were categorised as Dexamethasone patients and 40 (17 males and 23 females; mean age: 39.28±7.80 years) as methylprednisolone patients, there were significant improvement in mean score of VAS and ODI in both the groups (p-value <0.05). At six months, both treatment groups maintained initial observed improvements, with no significant differences between groups on the VAS {95% Confidence Interval (CI), -0.02 to 0.4; p-value=0.07} and ODI (95% CI,-0.21 to 3.43; p-value=0.08). Conclusion: Non-particulate steroid dexamethasone was similar in efficacy to the particulate steroid methylprednisolone in lumbar TFESI. However, in view of the greater safety profile of dexamethasone, it is suggested that dexamethasone may be used as the preferred agent in lumbar TFESI.

A comparative study of efficacy between transforaminal epidural injection and selective nerve root block in disc prolapse of L4-L5 and L5-S1

Background: To compare efficacy between transforaminal epidural injection (TFEI) and selective nerve root block (SNRB) in prolapsed L4-L5 and L5-S1 disc.Methods: This study was a randomized parallel group open label interventional study. Patients suffering from low back pain (LBP) with radiation due to prolapsed inter-vertebral disc (PIVD) were selected for intervention (n=78). After computer generated randomization, they were allocated into two groups (TFEI group and SNRB group) consisting 39 patients in each group. Each patient received combination of 2 ml of depot methylprednisolone acetate (40 mg/ml) and 1 ml of 0.25% preservative free bupivacaine under fluoroscopy guidance. Primary outcome measures were visual analogue scale (VAS) score of LBP and VAS score of radiation pain. Secondary outcome measure was Oswestry LBP disability questionnaire (ODQ) score.Results: At 1-day post-intervention TFEI group showed statistically significant improvement in VAS score of LBP (p=0.000) as compared to SNRB group. At 1-month post-intervention TFEI group showed statistically significant improvement in VAS score of LBP (p=0.000) and VAS score of radiation pain (p=0.000) as compared to SNRB group. At 3-month post-intervention TFEI group again showed statistically significant improvement in VAS score of LBP (p=0.000), VAS score of radiation pain (p=0.000), and ODQ score (p=0.000) as compared to SNRB group.Conclusions: TFEI is better than SNRB in terms of improvement in LBP, radiation pain, and functional activity up to 3-month post-intervention.