A series of transforaminal epidural steroid injections in acute lumbar disc herniation with unilateral radiculopathy

Jay V Turakhiya; Himanshu N Parmar; Kushal C Zala; Nikunj D Maru; Anant C Prajapati

doi:10.4103/jodp.jodp_18_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 5 | Issue : 3 | Page : 162-166

A series of transforaminal epidural steroid injections in acute lumbar disc herniation with unilateral radiculopathy

Jay V Turakhiya, Himanshu N Parmar, Kushal C Zala, Nikunj D Maru, Anant C Prajapati
Department of Orthopaedics, P.D.U Medical College and Civil Hospital, Rajkot, Gujarat, India

Date of Submission	24-Feb-2022
Date of Decision	20-Mar-2022
Date of Acceptance	21-Apr-2022
Date of Web Publication	1-Sep-2022

Correspondence Address:
Jay V Turakhiya
P.D.U Medical College, Rajkot, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_18_22

Abstract

Objective: To evaluate functional outcomes of patients suffering from unilateral lower limb radiculopathy due to lumbar disc herniation conservatively treated with transforaminal epidural steroid injection (TFESI). Materials and Methods: It is a prospective study of 100 patients. We correlated clinical findings with magnetic resonance imaging. The patients are treated with dexamethasone injection through transforaminal epidural space under C-ARM guidance using Kambin's triangle approach with follow-up at 3 weeks, 6 weeks, 9 weeks, 12 weeks, and 24 weeks. Assessment of functional outcomes is done by visual analog scale (VAS) and modified Oswestry disability index (ODI). Results: Eighty-eight percent of patients significantly improved their radicular pain, according to the VAS scoring system and modified ODI. The mean modified ODI score of preinjection was found to be 64.18; it was reduced to 33.9 at 3 weeks, 30.82 at 6 weeks, 24.04 at 9 weeks, 22.04 at 12 weeks, and 19.38 at 6 months. The t = 18.49 and the P < 0.00001. Preinjection mean VAS was 8, 3.98 at 3 weeks, 3.28 at 6 weeks, 3.04 at 9 weeks, 2.72 at 12 weeks, and reduced to 2.14 at 24 weeks. The t = 19.83 and the P < 0.00001. There were no complications seen during our study. Conclusion: Our study justifies that unilateral lower limb radiculopathy due to lumbar disc herniation can be well managed by TFESI without any complication. It is very less invasive technique, safe, and effective for pain relief.

Keywords: Lumbar disc herniation, modified Oswestry disability index, radiculopathy, transforaminal epidural steroid injections, visual analog scale

How to cite this article:
Turakhiya JV, Parmar HN, Zala KC, Maru ND, Prajapati AC. A series of transforaminal epidural steroid injections in acute lumbar disc herniation with unilateral radiculopathy. J Orthop Dis Traumatol 2022;5:162-6

How to cite this URL:
Turakhiya JV, Parmar HN, Zala KC, Maru ND, Prajapati AC. A series of transforaminal epidural steroid injections in acute lumbar disc herniation with unilateral radiculopathy. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Jun 6];5:162-6. Available from: https://jodt.org/text.asp?2022/5/3/162/355239

Introduction

Low back pain is the most common issue in routine orthopedics practice in around 90% of the patients, and the cause of pain with radiculopathy is due to prolapse disc.^[1],[2] The lumbar disc herniation can be associated with significant pain and associated disability. There are three types according to duration: acute (<4 weeks), subacute (4–12 weeks), and chronic (>12 weeks). Nerve root compression by a herniated disc is thought to be the cause of radiculopathy, but it can also occur in the absence of nerve compression,^[3] so even nerve root inflammation is an important factor for developing radiculopathy.^[4],[5] Wilby et al.^[6] suggested in their study of 163 patients that transforaminal epidural steroid injection (TFESI) should be considered as a first invasive treatment option against surgery along with the safety and cost-effectiveness for patients with sciatica secondary to herniated lumbar disc with symptoms duration up to 12 months without neurological deficit. The first documented epidural injection in the history of humankind was given in 1901 using the caudal approach, where cocaine was used to treat such patients of low backache with radiculopathy.^[7] The use of epidural steroid injection for the treatment was first reported in 1953.^[8] Steroids reduce inflammation by inhibiting proinflammatory mediators such as phospholipase A2 and histamine and by the action of stabilizing hyperexcitable nerve membranes.^[9],[10] After exposure to the host immune system, various ingredients of the nucleus pulposus (NP) were found to cause autoimmune reactions during intervertebral disc (IVD) degeneration progress.^[11],[12] Thus, the IVD has been identified as an immune-privileged organ. The autoimmune response and downstream cascade reaction start when the blood-NP barrier is damaged. As early as the 1960s, studies have found evidence of autoimmune response of the degenerated NP in patients and animals^[13],[14] and indicated that radicular pain of a lumbar disc herniation results from chemicals of exposure of the NP and related autoimmune response.^[15] Treatment of lumbar disc herniation remains controversial. Epidural steroid injection reduces the need for oral or IV analgesics. It also prevents unnecessary surgical intervention. Our diagnosis is made easy by magnetic resonance imaging (MRI) with high sensitivity and specificity.

In addition to being a less invasive procedure, epidural steroid injections have less morbidity and mortality compared to surgical procedures; however, there are reports of serious complications such as arachnoiditis and meningitis which are very rare according to Goodman et al.'s study of complications and pitfalls of lumbar interlaminar and transforaminal epidural injections.^[16] This study is aimed to evaluate the outcome of transforaminal injections before surgical interventions in patients with radiculopathy who have failed to respond other conservative methods such as nonsteroidal anti-inflammatory drugs (NSAIDS) and physiotherapy and also the potency of injection dexamethasone is assessed for pain relief rather than the use of usual injection triamcinolone.

Materials and Methods

This prospective and institutional study was conducted from April 2020 to April 2021, where 100 patients were consulted at outpatient department at PDU Civil Hospital, Rajkot. Proper informed consent was taken from patients before the start of the study.

The inclusion criteria were patients from age 18 years to 60 years of both sexes, acute to subacute low backache with unilateral radiculopathy for a minimum period of 3 months, MRI-proven lumbar disc prolapse, with >4/5 muscle power and ± hypoesthesia in affected dermatome before the procedure with intact bowel and bladder status, previously conservatively managed with analgesics for at least 3 weeks. We excluded bilateral lower limb radiculopathy, any systemic infection or local infection at the injection site, profound neurological deficit, cauda equina syndrome, patients on anticoagulation therapy or having any bleeding disorder, patients with congestive heart failure or uncontrolled blood sugars, spinal deformity or history of previous spinal surgery, pregnant females or lactating females, patients with underlying malignancy, and patients on immunosuppressive therapy. All the patients included in the study were selected randomly and not responding to conservative treatment, i.e., NSAIDs, oral steroids, muscle relaxants, transcutaneous electrical nerve stimulation, and physiotherapy. Epidural steroid injections are given by the transforaminal approach.

All the patients planned for the injection were kept nil by mouth for 2 hours before the procedure with routine laboratory investigations (complete blood count, random blood sugar, and renal function test) and blood pressure was checked. All resuscitative machines and anesthesia equipment were kept stand by to be ready for any possible adverse reaction. The procedure was done in prone position in the operation theater. Under all aseptic precautions, disc level was located by surface anatomy with fluoroscopy C-ARM guidance. We have used Kambin's triangle approach. The site of injection was first confirmed by injecting iohexol dye 0.5 ml under local anesthesia under C-ARM guidance then 2 ml of 0.4% w/v dexamethasone combined with 0.5 ml of 0.5% bupivacaine with 22-gauge spinal needle injected through transforaminal epidural space. After the procedure, the patient was kept under observation for 30 min. After examining sensory and motor functions, patient was discharged with tablet paracetamol if required. No brace was prescribed. Follow-up was done at 3 weeks, 6 weeks, 9 weeks, 12 weeks, and 24 weeks. The patients were assessed for lower back pain and lower extremity pain based on a visual analog scale (VAS) score from 0 (no pain) to 10 (worst pain possible) and modified Oswestry disability index (ODI).

Kambin's triangle approach

Kambin's triangle is defined as a right triangle over the dorsolateral disc. The hypotenuse is the exiting nerve root, the base (width) is the superior border of the caudal vertebra, and the height is the dura/traversing nerve root.

[Figure 1]a shows lumbar disc herniation at L3-L4, L4-L5 intervertebral level (sagittal section), [Figure 1]b suggests left side paracentral disc herniation at L4-L5 IVD (axial view), and [Figure 1]c shows image intensifier guided procedure of TFESI.

Figure 1: (a) MRI lumbar spine sagittal section shows lumbar disc herniation at L3-L4, L4-L5 vertebral level. (b) MRI lumbar spine axial view of L4-L5 intervertebral disc level shows left side paracentral disc herniation. (c) Anteroposterior view of lumbar spine on IITV image shows transforaminal epidural steroid injection given at left sided L4-L5 intervertebral level. MRI: Magnetic resonance imaging

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MRI of lumbar spine in [Figure 2]a shows lumbar disc herniation at L4-L5 intervertebral level (sagittal view), [Figure 2]b shows right side paracentral disc herniation at L4-L5 IVD, and [Figure 2]c shows image intensifier guided procedure of TFESI.

Figure 2: (a) MRI lumbar spine sagittal section shows Lumbar disc herniation at L4-L5 intervertebral level. (b) MRI lumbar spine axial view of L4-L5 Intervertebral disc level shows right side paracentral disc herniation. (c) Anteroposterior view of lumbar spine on IITV Image shows transforaminal epidural steroid injection given at right sided L4-L5 intervertebral level. MRI: Magnetic resonance imaging

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Results

In this study, 100 patients were enrolled of which 88% (88 patients) got a significant improvement in the symptoms, according to the VAS scoring system and modified ODI. In this study, according to age group distribution, there was a maximum number of patients found in the age group of 46–50 years were 32 patients, followed by an age group of 41–45 years, there were 22 patients. Two patients were in the 21–25 years age group, six patients in the 26–30 years age group, 8 patients in the 31–35 years age group, 10 patients in the 36–40 years age group, 12 patients in the 51–55 years age group, and 8 patients in the 56–60 years age group. In this study, the mean age is 44.68 years, and the standard deviation is 8.5. In this study, we enrolled 32 male patients and 68 female patients between the age group of 18–60 years. The rest of the 12% (12 patients) got little or no relief at all, even after 3 doses of epidural steroid injections. Out of this, 72% (72 patients) improved with only one injection and 11% (11 patients) with the 2^nd dose. The remaining 5% (5 patients) got satisfactory results only after the 3^rd dose. According to lumbar intervertebral disc herniation level, L4-L5 level was affected in the highest number of patients (44 patients), followed by L5-S1 level (40 patients), followed by L3-L4 level (14 patients) and L2-L3 level (2 patients) [Table 1]. We gave TFESI to all 100 patients and functional assessment was done by modified ODI score ODI and VAS. We had also advised patients for physiotherapy and lifestyle modifications. Regular follow-up of 3 weeks, 6 weeks, 9 weeks, 12 weeks, and 24 weeks had been taken and the mean modified ODI score of preinjection was found to be 64.18 after TFESI at 3 weeks which was reduced to 33.9, after 6 weeks it was 30.82, at 9 weeks it was 24.04, at 12 weeks it was 22.04, and further reduced to 19.38 at 24 weeks. The modified ODI score of 0–20 suggests minimal disability. In this study at 24-week follow-up mean modified ODI score was 19.38 which suggests a minimal disability and patients have pain relief from unilateral radicular pain due to lumbar disc herniations [Table 2] and [Graph 1]. Preinjection mean VAS was 8 and after TFESI at follow-up of 3 weeks, 6 weeks, 9 weeks, 12 weeks, and 24 weeks, the mean VAS were 3.98, 3.28, 3.04, 2.72, and 2.14. VAS score 1–3 suggest minimal pain and at 6-month follow-up mean VAS score is 2.14, and patients have pain relief from unilateral radicular pain due to lumbar disc herniations [Table 3] and [Graph 2]. According to the modified ODI score, the t = 18.49 and the P < 0.00001 (P < 0.05 is significant) for the comparison of preinjection and final follow-up; according to the VAS score, the t = 19.83 and the P < 0.00001 (P < 0.05 is significant) for the comparison of preinjection and final follow-up.

Table 1: Number of patients according to the level of intervertebral disc herniation

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Table 2: Mean of modified Oswestry disability index score and standard deviation of 24-week follow-up after transforaminal epidural steroid injection

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Table 3: Mean visual analog scale score and standard deviation of 24-week follow-up after transforaminal epidural steroid injection

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It was found that protrusive and extrusive type of disc herniations gave similar positive response on giving transforaminal injections while the response of sequestrated type was lesser in comparison [Table 4] and [Table 5].

Table 4: Degree of disc herniation at different levels

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Table 5: Degree of disc herniation and its response to injections

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Discussion

Sciatica due to a lumbar IVD herniation is one of the most common causes of radicular pain in an adult working population.^[17] Epidural steroid injection is an effective and less invasive method of treating patients with low backache with unilateral radiculopathy. Although there are risks such as infection, epidural hematoma, dura-cutaneous fistula, postdural puncture, and headache associated with the procedure, the risk is quite low. Nausea, vomiting, dizziness, and vasovagal shock can also occur, and the patients should be warned regarding all these complications before the procedure, but there were no complications seen in this study. It was a prospective study with a reasonably good patient size, making it generalizable. Bogduk carried out 40 studies on more than 4000 patients regarding epidural steroid injections and 36 studies recommended its use in the treatment.^[18] Another study carried out by Wani et al. on over 150 patients with a follow-up of 2 years found an overall success rate of 69%.^[19] Epidural steroid injection has also been recommended by the North American Spine Society and Agency for Health Care Policy and Research for the management of low backache with radiculopathy.^[20] Blankenbaker et al. and Sharma and Stedman carried out two different individual studies and found that the success rate depends on the duration of back pain. For a duration of fewer than 3 months, the success rate is 83%–100%, and the success rate declines as the duration of symptoms increases.^[21],[22] In 2010, the study of 150 patients was done by Ghahreman et al.^[23] for transforaminal steroid injection with lumbar disc herniation with radiculopathy by using the transforaminal epidural steroid injectate of 2.5 ml was comprised 70 mg triamcinolone and 0.75 ml of 5% bupivacaine. No complications from the injections were identified. This study concludes that TFESI is a viable alternative to surgery for lumbar radicular pain due to disc herniation. In 2002, Vad et al.^[24] conducted a study of 50 consecutive patients with lumbar disc herniation with radiculopathy. Of the 50 consecutive patients included in the study, 25 were treated with TFESI and 25 received saline trigger point injection at the end of 12 months and outcomes were assessed using VAS, Roland Morris, and patient satisfaction. The success rate was significant with the TFESI group (84%) compared to the saline trigger point group (48%).

Conclusion

We conclude that there is a significant functional improvement both statistically and clinically in patients with unilateral radicular pain due to lumbar disc herniation after giving TFESIs. We have used dexamethasone which has a very potent anti-inflammatory property. This is a very safe, less invasive technique and in our study, there are no complications seen. In this study 88% of patients got relief from unilateral radicular pain due to lumbar disc herniation. In this study, we have used Kambin's triangle approach. In our study, we have used Kambin's triangle approach. It is a very safe and proper approach for giving a TFESI procedure. This TFESI procedure also avoids or may postpone the need for surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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