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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 29  |  Issue : 3  |  Page : 155-161

Effect of transforaminal epidural block for relief of chronic low back pain with radiculopathy of multiple etiologies


Department of Anaesthesiology, R. G. Kar Medical College, Kolkata, West Bengal, India

Date of Web Publication21-Sep-2015

Correspondence Address:
Dr. Dipasri Bhattacharya
B26/10, Abhyudoy Housing, EKTP Phase IV, P. O. EKT, Kolkata - 700 107, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.165837

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  Abstract 

Introduction: Low back pain is one of the most common causes of chronic pain syndrome. Epidural steroids are being used for relieving mechanical causes of back pain, accompanied by signs of nerve root irritation with good results. Transforaminal epidural block at a particular level is a convenient route for steroid injection. Methods: The study was carried out on patients attending our pain clinic complaining of low back pain with radiculopathy where conservative therapy failed. Patients were divided into three groups (20 in each, allocated by random number table), 1 st one having collapsed vertebra, 2 nd one having disc protrusion following degenerative changes, 3 rd one having Grade I spondylolisthesis in lumbosacral region. Each of them received transforaminal epidural block at one level (L1/L2) with a dose of 40 mg of depot methyl prednisolone, diluted with 1 ml of 0.25% isobaric bupivacaine (to make a volume of 2 ml for each level on both sides). Initial pain response (at 1 h) was assessed by visual analogue scale (VAS). Long-term pain and disability were assessed (at 1 st , 3 rd and 6 th months) by using VAS score and oswestry disability index (ODI) score. Results: Significant improvement in VAS and ODI score were observed in cases of collapsed vertebra and disc protrusion due to degenerative changes but in the cases of Grade I spondylolisthesis no such improvement was observed. Conclusion: Transforaminal epidural block causes significant relief of symptoms where compression of nerve roots at a particular level causing radiculopathy as in collapsed vertebra or disc protrusion, but not in spondylolisthesis.

Keywords: Low back pain, radiculopathy, relief of pain, transforaminal epidural block


How to cite this article:
Guha R, Bhattacharya D. Effect of transforaminal epidural block for relief of chronic low back pain with radiculopathy of multiple etiologies. Indian J Pain 2015;29:155-61

How to cite this URL:
Guha R, Bhattacharya D. Effect of transforaminal epidural block for relief of chronic low back pain with radiculopathy of multiple etiologies. Indian J Pain [serial online] 2015 [cited 2019 Jul 19];29:155-61. Available from: http://www.indianjpain.org/text.asp?2015/29/3/155/165837


  Introduction Top


Low back pain is one of the frequent presentations of chronic pain syndrome. It is termed as chronic where pathological and/or anatomical instability persist beyond 3 months. [1] 70-85% of the adults experience at least one episode of low back pain at some time during their lifetime. [1] The direct and indirect costs of low back pain in terms of quality of life, productivity, and employee absenteeism are enormous, making this common condition the single largest contributor to musculoskeletal disability worldwide. [2] Both sexes are involved and common age groups are 30-50 years. Smokers are at increased risk. [3]

Common causes of low back pain are degenerative disc disorder, vertebral collapse, and spondylolisthesis. All of these can cause radiculopathy depending upon the site and extent of compression. A multimodal, multidisciplinary approach, focusing on short-term analgesics, physical therapy, and patient education, was the mainstay for the management of low back pain. [4] Since the introduction of epidural analgesia, and later the use of epidural steroids, [5] it's long been accepted that mechanical causes of back pain, accompanied by signs of nerve root irritation, may respond to epidural steroid injections (ESIs). [6],[7],[8] Transforaminal epidural route of steroid injection provides good symptomatic relief in chronic low back pain with radiculopathy, [8],[9] especially when the pathology is affecting the vertebral column at a particular level.

Aim of our study was to compare the outcomes of transforaminal ESI in patients with chronic low back pain with radiculopathy of different etiologies such as collapsed vertebra, disk protrusion due to degenerative diseases and Grade I spondylolisthesis. This may help us to select the appropriate patient for transforaminal ESI, so that the outcome will be better.


  Materials and Methods Top


After approval from Institutional Ethical Committee and informed written consent from the patient, a randomized single-blinded study was conducted. Patients were selected from those attending our pain clinic. Many of them were initially referred by a preselected group of specialists including neurologists, neurosurgeons, orthopedic surgeons, rheumatologists, and rehabilitation physicians who were familiar with the selection criteria. Inclusion and exclusion criteria are enlisted below.

Inclusion criteria

  1. Chief complaint of low back pain radiating to one lower extremity.
  2. Failed analgesic and nonpharmacologic therapy trial of at least 3 months.
  3. Duration of current back and leg pain for >3 months and less than a year.
  4. Correlation between the clinically determined level(s) of radiculopathy and the findings on magnetic resonance imaging (MRI).
  5. Both sex.
  6. American Society of Anesthesiologists Physical status I and II.


Exclusion criteria

  • Multilevel degenerative spine disease, unstable spine, spondylolisthesis (>Grade 1).
  • Arachnoiditis, progressive neurologic deficit.
  • Co-morbidities like uncontrolled diabetes and uncontrolled hypertension.
  • Patient's refusal.
  • Myelographic contrast allergy, steroid allergy, local anesthetic allergy.


They were divided into three groups as per the MRI findings, each group were allocated 20 patients according to a random number table:

Group A: Vertebral collapse (n = 20).

Group B: Disc protrusion due to degenerative changes (n = 20).

Group C: Grade I spondylolisthesis (n = 20).

Intervention technique

Before taking the patient to the intervention room, some routine investigations were done, such as blood for hemoglobin level, total leucocyte count, differential leucocyte count, platelet count, blood sugar, serum urea, creatinine, uric acid, bleeding time, and coagulation time.

On arrival in the operating room after 6 h of fasting for solid food, routine monitors like noninvasive blood pressure, electrocardiogram, and pulse oximetry were used. Peripheral intravascular cannulation was established and Ringer's lactate solution was started slowly. All patients received antibiotic ceftriaxone 1 g after proper skin test and resuscitation equipments were checked.

After all these preparatory steps, patients were placed on intervention table in prone position with a pillow under the abdomen. Antiseptic dressing and draping were done and the site of needle insertion was marked with a radiopaque marker (6'o clock position of the pedicle) after proper squaring of the vertebrae was achieved in the antero-posterior view under fluoroscopy. A 22-gauge 9 cm spinal needle was directed under intermittent fluoroscopic guidance into the neural foramens such that the tip rested within the triangle composed of the nerve root medially, the bony pedicle superiorly, and the lateral border of the foramen laterally. Depth of needle insertion was perceived by lateral fluoroscopic view [Figure 1], [Figure 2], [Figure 3].2 ml of contrast (Iohexol) injected through the needle for the final confirmation of the epidural space. 1/2 ml of 20 mg/ml depo-medrol was mixed with 1.5 ml of 0.25% isobaric bupivacaine and total 2 ml of drug was injected through the needle on both sides at the same level. Dilution of contrast after drug injection was confirmed under fluoroscopy [Figure 4]. All injections were given at L1/L2 level, depending on the pathology.
Figure 1: Antero-posterior view of lumber spine and needle


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Figure 2: Dye disposition antero-posterior view


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Figure 3: Dye disposition lateral view


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Figure 4: Dye dilution after drug injection antero-posterior view


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Patients were kept under observation and hemodynamic monitoring was done till 1 h after the intervention. Initial pain response (after 1 h) was assessed by visual analogue scale (VAS) scale. All patients were followed-up in pain clinic outdoor. They were advised not to bend forward or lift heavy weight and were also advised to take tablet (pregabalin + methylcobalamin) combination once daily at night along with (tramadol + paracetamol) combination twice daily.

Long-term pain response and disability after 3 and 6 months were assessed by using VAS scale and oswestry disability index (ODI) score, respectively. Those who had VAS score <3 and more than 50% disability reduction after injection were defined as responders.

The VAS and ODI questionnaire are shown below:



Visual analogue scale

Oswestry disability index questionnaire helps to detect how pain has affected one's ability to manage day to day life. It includes questions under 10 headings as follows:

  1. Pain intensity.
  2. Personal care (washing, dressing etc.).
  3. Lifting.
  4. Walking.
  5. Sitting.
  6. Standing.
  7. Sleeping.
  8. Sex life (if applicable).
  9. Social life.
  10. Travelling.


0-20% = Minimum disability

21-40% = Moderate disability

41-60% = Severe disability

61-80% = Crippled

81-100% = Bedridden


  Results Top


Visual analogue scale score analysis

Done by one-way ANNOVA followed by Dunnett's multiple comparison test [Diagram 1, Diagram 2, Diagram 3 and [Table 1], [Table 2], [Table 3], [Table 4]].
Table 1: Demographic data


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Table 2: VAS scores in Group A


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Table 3: VAS scores in Group B


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Table 4: VAS scores in Group C


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Oswestry disability index score analysis

Done by one-way ANNOVA followed by Dunnett's multiple comparison test [Diagram 4, Diagram 5, Diagram 6 and [Table 5], [Table 6], [Table 7]].
Table 5: ODI scores in Group A


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Table 6: ODI scores in Group B


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Table 7: ODI scores in Group C


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  Discussion Top


Chronic low back pain often radiates to hips, legs and increases while walking, sitting, bending, lifting, and twisting. There are different mechanism of chronic pain like multiple noxious stimulation, excess nociception which sensitize the pain pathway at multiple levels, and excess neurotransmitter release causing hyperalgesia or wind up. [10],[11] Water and protein content of cartilage changes with advancing age resulting in weaker, fragile and thin cartilage. Disks, partly composed by cartilage is prone to wear and tear, and subsequently inflammation with aging.

Lower back pain with radicular symptoms that correlate clinically with examination and imaging is an efficacious target for lumbar ESI in short-term pain management. [12],[13] Corticosteroid has different modalities of action in reducing pain. These are membrane stabilization, blockade of phospholipase A2, inhibition of synthesis or release of pro-inflammatory substances, suppression of sensitization of dorsal horn neurons, and reversible local anesthetic effect. [8],[14],[15] Maximal beneficial effects of epidural long acting steroid is usually experienced after few weeks of injection though there is an individual variation of receptor response to methyl prednisolone.

Local anesthetics, when injected epidurally suppress nociceptive discharge, blocks axonal transport, reflex sympathetic arc, provide anti-inflammatory action, and thus providing analgesia. Local anesthetics in epidural injection have long-term effectiveness in improving the quality of life. [16],[17]

Transforaminal epidural injection is considered as an invasive procedure and causes improvement in symptoms. [18] Rosenberg SK et al. observed that transforaminal ESIs can offer significant pain reduction up to 1-year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis. [19] Botwin KP et al. observed that fluoroscopically guided transforaminal ESIs may help to reduce radicular pain and improve standing and walking tolerance in patients with degenerative lumbar spinal stenosis. [20]

In our study, initial improvement of VAS score (1 h postinjection) was due to the action of local anesthetic and hence comparable in all three groups. Although in the long run, low back pain with radiculopathy due to collapsed vertebrae and disc protrusion due to degenerative changes showed comparable, improvement in VAS score and ODI score, whereas that due to Grade I spondylolisthesis showed less improvement in both scoring.

No major complication was encountered during the procedure except nausea, dizziness, etc. which were spontaneously resolved.


  Conclusion Top


Transforaminal epidural injection of steroid and local anesthetic can cause significant improvement in conditions where the nerve root compression is at a particular level causing radiculopathy. It was also observed that the effect was more pronounced in the case of vertebral collapse or disc bulge due to degenerative changes, but in case of Grade I spondylolisthesis it was not that much effective.

 
  References Top

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Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 2010;10:514-29.  Back to cited text no. 4
    
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Manchikanti L, Datta S, Gupta S, Munglani R, Bryce DA, Ward SP, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: Part 2. Therapeutic interventions. Pain Physician 2010;13:E215-64.  Back to cited text no. 7
    
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Young IA, Hyman GS, Packia-Raj LN, Cole AJ. The use of lumbar epidural/transforaminal steroids for managing spinal disease. J Am Acad Orthop Surg 2007;15:228-38.  Back to cited text no. 8
    
9.
Gharibo CG, Varlotta GP, Rhame EE, Liu EC, Bendo JA, Perloff MD. Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: A randomized, blinded, prospective outcome study. Pain Physician 2011;14:499-511.  Back to cited text no. 9
    
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Johansson A, Hao J, Sjölund B. Local corticosteroid application blocks transmission in normal nociceptive C-fibres. Acta Anaesthesiol Scand 1990;34:335-8.  Back to cited text no. 10
    
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LaMotte RH, Shain CN, Simone DA, Tsai EF. Neurogenic hyperalgesia: Psychophysical studies of underlying mechanisms. J Neurophysiol 1991;66:190-211.  Back to cited text no. 11
    
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Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997;336:1634-40.  Back to cited text no. 12
    
13.
Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology (Oxford) 2005;44:1399-406.  Back to cited text no. 13
    
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Johansson A, Bennett GJ. Effect of local methylprednisolone on pain in a nerve injury model. A pilot study. Reg Anesth 1997;22:59-65.  Back to cited text no. 14
    
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Tachihara H, Sekiguchi M, Kikuchi S, Konno S. Do corticosteroids produce additional benefit in nerve root infiltration for lumbar disc herniation? Spine (Phila Pa 1976) 2008;33:743-7.  Back to cited text no. 15
    
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Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, et al. Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: Single injection versus continuous infusion. Clin J Pain 2007;23:551-7.  Back to cited text no. 16
    
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Bisby MA. Inhibition of axonal transport in nerves chronically treated with local anesthetics. Exp Neurol 1975;47:481-9.  Back to cited text no. 17
    
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Manchikanti L. Role of neuraxial steroids in interventional pain management. Pain Physician 2002;5:182-99.  Back to cited text no. 18
    
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Rosenberg SK, Grabinsky A, Kooser C, Boswell MV. Effectiveness of transforaminal epidural steroid injections in low back pain: A one year experience. Pain Physician 2002;5:266-70.  Back to cited text no. 19
    
20.
Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Sanelli JT, Freeman ED, et al. Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: An outcome study. Am J Phys Med Rehabil 2002;81:898-905.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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