Skip to main content

Advertisement

SpringerLink
Log in

CT-guided transforaminal epidural steroid injections: do needle position and degree of foraminal stenosis affect the pattern of epidural flow?

  • Scientific Article
  • Published:
Skeletal Radiology Aims and scope Submit manuscript

Abstract

Objective

To determine the effect of needle position and foraminal stenosis on contrast flow directionality during CT-guided transforaminal epidural steroid injections (TFESI).

Materials and methods

One hundred five consecutive CT-guided injections were performed in 68 patients (mean age, 65.5 years) from January 1 to December 31 2017, all with preceding MRI. Two readers independently reviewed CT images to assess needle position and to determine direction of contrast flow, which was defined as central or peripheral. The MRIs were independently reviewed by the readers to determine the degree of foraminal stenosis. Inter-reader agreement for both was evaluated with the kappa statistic. Analyses were performed to determine effect of needle position, degree of foraminal stenosis, and volume of contrast injected with directionality of contrast flow, and association between contrast flow directionality with immediate post-procedural pain scores.

Results

Central direction of contrast flow was demonstrated in 41/78 (52.6%) of cases with posterolateral needle position, and 20/27 (74.1%) with central or anteromedial needle position (p = 0.07). There was no difference in direction of contrast flow with high-grade versus absence of high-grade neuroforaminal narrowing, or with volume of contrast injected. There was no difference in immediate post-procedure pain scores regardless of contrast flow directionality.

Conclusions

Needle position is not significantly associated with contrast flow directionality during CT-guided TFESI, although there was a trend towards relatively decreased central flow with posterolateral positioning. Degree of foraminal stenosis and volume of injected contrast did not affect contrast flow directionality. There was no difference in immediate post-procedural pain scores with either direction of contrast flow.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Boswell MV, Hansen HC, Trescot AM, Hirsch JA. Epidural steroids in the management of chronic spinal pain and radiculopathy. Pain Physician. 2003;6(3):319–34.

    PubMed  Google Scholar 

  2. Manchikanti L, Staats PS, Singh V, Schultz DM, Vilims BD, Jasper JF, et al. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2003;6(1):3–81.

    PubMed  Google Scholar 

  3. Ackerman WE, Ahmad M. The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesth Analg. 2007;104(5):1217–22. tables of contents

    Article  Google Scholar 

  4. Manchikanti L. Transforaminal lumbar epidural steroid injections. Pain Physician. 2000;3(4):374–98.

    CAS  PubMed  Google Scholar 

  5. Gupta R, Singh S, Kaur S, Singh K, Aujla K. Correlation between epidurographic contrast flow patterns and clinical effectiveness in chronic lumbar discogenic radicular pain treated with epidural steroid injections via different approaches. Korean J Pain. 2014;27(4):353–9.

    Article  Google Scholar 

  6. Vassiliev D. Spread of contrast during L4 and L5 nerve root infiltration under fluoroscopic guidance. Pain Physician. 2007;10(3):461.

    PubMed  Google Scholar 

  7. Furman MB, Lee TS, Mehta A, Simon JI, Cano WG. Contrast flow selectivity during transforaminal lumbosacral epidural steroid injections. Pain Physician. 2008;11(6):855–61.

    PubMed  Google Scholar 

  8. Everett CR Shah RVSN. A systematic review of diagnostic utility of selective nerve root blocks. Pain Physician. 2005;8(2):225–34.

    PubMed  Google Scholar 

  9. Datta S, Everett A, Trescot A, Schultz D, Adlaka R, et al. An updated systematic review of the diagnostic utility of selective nerve root blocks. Pain Physician. 2007;10(1):113–28.

    PubMed  Google Scholar 

  10. Lew HL, Coelho P, Chou LH. Preganglionic approach to transforaminal epidural steroid injections. Am J Phys Med Rehabil. 2004;83(5):378.

    Article  Google Scholar 

  11. Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. Radiology. 2007;245(2):584–90.

    Article  Google Scholar 

  12. Pairuchvej S, Arirachakaran A, Keorochana G, Wattanapaiboon K, Atiprayoon S, Phatthanathitikarn P, et al. The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis. Neurosurg Rev. 2017;1-8.https://doi.org/10.1007/s10143-017-0826-z.

    Article  Google Scholar 

  13. Jasper JF. Lumbar retrodiscal transforaminal injection. Pain Physician. 2007;10(3):501–10.

    PubMed  Google Scholar 

  14. Irwin A, Khan AL, Fender D, Sanderson PL, Gibson MJ. The role of needle tip position on the accuracy of diagnostic selective nerve root blocks in spinal deformity. Eur Spine J. 2014;23(1):33–9.

    Article  Google Scholar 

  15. Wolff AP, Groen GJ, Wilder-Smith OH. Influence of needle position on lumbar segmental nerve root block selectivity. Reg Anesth Pain Med. 2006;31(6):523–30.

    Article  Google Scholar 

  16. Mandell JC, Czuczman GJ, Gaviola GC, Ghazikhanian V, Cho CH. The lumbar neural foramen and transforaminal epidural steroid injections: an anatomic review with key safety considerations in planning the percutaneous approach. Am J Roentgenol. 2017;209(1):W26–35.

    Article  Google Scholar 

  17. Pfirrmann CWA, Oberholzer PA, Zanetti M, Boos N, Trudell DJ, Resnick D, et al. Selective nerve root blocks for the treatment of sciatica: evaluation of injection site and effectiveness—a study with patients and cadavers. Radiology. 2001;221(3):704–11.

    Article  CAS  Google Scholar 

  18. Lee S, Lee JW, Yeom JS, Kim K-J, Kim H-J, Chung SK, et al. A practical MRI grading system for lumbar foraminal stenosis. AJR Am J Roentgenol. 2010;194(4):1095–8.

    Article  Google Scholar 

  19. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74.

    Article  CAS  Google Scholar 

  20. Desai MJ, Shah B, Sayal PK. Epidural contrast flow patterns of transforaminal epidural steroid injections stratified by commonly used final needle-tip position. Pain Med. 2011;12(6):864–70.

    Article  Google Scholar 

  21. Stalcup ST, Crall TS, Gilula L, Riew KD. Influence of needle-tip position on the incidence of immediate complications in 2,217 selective lumbar nerve root blocks. Spine J. 2006;6(2):170–6.

    Article  Google Scholar 

  22. Atluri S, Glaser SE, Shah RV, Sudarshan G. Needle position analysis in cases of paralysis from transforaminal epidurals: consider alternative approaches to traditional technique. Pain Physician. 2013;16(4):321–34.

    PubMed  Google Scholar 

  23. Park JW, Nam H-S, Park Y. Usefulness of posterolateral transforaminal approach in lumbar radicular pain. Ann Rehabil Med. 2011;35(3):395–404.

    Article  Google Scholar 

  24. Zhu J, Falco FJE, Formoso F, Onyewu O, Irwin FL. Alternative approach for lumbar transforaminal epidural steroid injections. Pain Physician. 2011;14(4):331–41.

    PubMed  Google Scholar 

  25. Makkar JK, Singh NP, Rastogi R. Volume of contrast and selectivity for lumbar transforaminal epidural steroid injection. Pain Physician. 2015;18(1):101–5.

    PubMed  Google Scholar 

  26. Castro WH, Grönemeyer D, Jerosch J, Seibel R, Lorenz G, Beutelstahl D, et al. How reliable is lumbar nerve root sheath infiltration? Eur Spine J. 1994;3(5):255–7.

    Article  CAS  Google Scholar 

  27. Lee JW, Kim SH, Lee IS, Choi JA, Choi JY, Hong SH, et al. Therapeutic effect and outcome predictors of sciatica treated using transforaminal epidural steroid injection. Am J Roentgenol. 2006;187(6):1427–31.

    Article  Google Scholar 

  28. Jeong YC, Lee CH, Kang S, Yoon JS. Contrast spread in the superoposterior approach of transforaminal epidural steroid injections for lumbosacral radiculopathy. Ann Rehabil Med. 2017;41(3):413–20.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA

    Nityanand Miskin, Glenn C. Gaviola, Varand Ghazikhanian & Jacob C. Mandell

Authors
  1. Nityanand Miskin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Glenn C. Gaviola
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Varand Ghazikhanian
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jacob C. Mandell
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nityanand Miskin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Miskin, N., Gaviola, G.C., Ghazikhanian, V. et al. CT-guided transforaminal epidural steroid injections: do needle position and degree of foraminal stenosis affect the pattern of epidural flow?. Skeletal Radiol 47, 1615–1623 (2018). https://doi.org/10.1007/s00256-018-3002-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00256-018-3002-9

Keywords

Search

Navigation