Outcomes of interlaminar and transforminal spinal injections.
Abstract: Epidural spinal injections can be administered via a translaminar or transforaminal route, depending on the clinical scenario. When it is more desirable to target a specific nerve root, a transforaminal approach is typically used, and when the target is more diffuse, a translaminar method is chosen. Both are commonly used and can be utilized similarly in the lumbar or cervical spine. However, it is essential that the clinician understand the risks and benefits of these injections. In the lumbar spine, both translaminar epidural steroid injections (TLESI) and transforaminal epidural steroid injections (TFESI) have been shown to provide up to 6 months of pain relief, though long-term benefits are less reliable. In the cervical spine, translaminar injections may provide longer relief and have a lower complication rate than cervical transforaminal injections. Proper technique is essential to minimize the rate of these rare but occasionally severe complications.
Article Type: Report
Subject: Injections, Spinal (Usage)
Injections, Spinal (Patient outcomes)
Spinal diseases (Care and treatment)
Spinal diseases (Patient outcomes)
Pain (Care and treatment)
Pain (Methods)
Authors: Landa, Joshua
Kim, Yong
Pub Date: 01/01/2012
Publication: Name: Bulletin of the NYU Hospital for Joint Diseases Publisher: J. Michael Ryan Publishing Co. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 J. Michael Ryan Publishing Co. ISSN: 1936-9719
Issue: Date: Jan, 2012 Source Volume: 70 Source Issue: 1
Accession Number: 301180440
Full Text: Epidural spinal injections are commonly used in the nonoperative management of cervical and lumbar spine pathology. They can be useful for both diagnostic and therapeutic purposes. Indications include neck or lower back pain with or without radiculopathy. Complications have occasionally been reported and can be devastating. It is, therefore, imperative that the administering clinician understand the existing literature for injections so that they can help patients make an informed decision as to whether these injections are in their best interest.

Spinal epidural steroid injections can be given in a translaminar or transforaminal fashion. Translaminar epidural steroid injections (TLESI) are more appropriate for patients with axial neck or lower back pain or spinal stenosis, while transforaminal epidural steroid injections (TFESI) are more appropriate for isolated lumbar or cervical nerve root irritation. Several studies have been performed to evaluate the efficacy of these injections, and there have been a number of reported complications of each type. Clinicians should be aware of the range of complications in order to best counsel their patients (Table 1).

Lumbar TLESI

Lumbar injections are commonly used in the nonoperative management of lower back pain with or without radiculopathy as well as for lumbar spinal stenosis. Contraindications such as previous laminectomy or active infection should be familiar to the practicing clinician. While the literature is still emerging with regard to efficacy, there are several valid randomized controlled trials that have sought to establish whether or not these injections should be used.

Carette and colleagues conducted a randomized controlled double blind trial of 158 patients with herniated nucleus pulposis randomized to steroid or saline lumbar TLESI. (1) At 3 weeks, the steroid group had better Oswestry scores and finger-floor distance as well as less pain. At 6 weeks, the steroid group had less pain, with no difference in any of the other outcome measures assessed in this study. By 3 months, there were no differences found between the two groups. Additionally, the same percentage of patients in both groups went on to surgery.

The WEST Study, published in Rheumatology in 2005, was a multi-center, double-blind, randomized, placebo-controlled, parallel-group trial that consisted of 288 patients that all had unilateral sciatica. (2) Patients were randomized into two groups; one group received three Lumbar TLESI with steroid, and the other group received an injection with interligamentous saline. They used the Oswestry low back pain disability questionnaire to evaluate outcomes. The investigators found that at 3 weeks 12.5% of steroid injection group and 3.7% of interligamentous saline groups had 75% or more improvement, which was a significant difference between the two groups. However, outcomes from 6 to 52 weeks failed to show any benefit in the group the received the lumbar TLESI with steroid compared to the group that was given injections with interligamentous saline.

These two studies demonstrated that there is excellent short-term relief in patients injected with lumbar TLESI. However, consistent long term relief is lacking. Supporting this idea was a study by Wilson-Macdonald and associates. (3) They studied 93 patients who were randomized to receive either an intramuscular steroid and anesthetic injection or lumbar TLESI for a compressed nerve root. They found a significant reduction in pain early on with TLESI without any long-term difference.

Recently, a systematic review of lumbar TLESI with or without steroid injections was conducted by Parr and coworkers. (4) The review was performed using the Cochrane Musculoskeletal Review Group criteria for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality criteria for observational studies. Short-term relief was classified as that lasting less than 6 months while long-term was considered relief for greater than 6 months. There is level II-2 positive evidence for pain relief from disc herniation and radiculitis. A significant limitation that they noted was that all studies involved injections that were "blind," meaning that no fluoroscopy was used for localization. Blind injections were subject to problems including extra epidural placement of the needle, intravascular placement of the needle, preferential cranial flow of the solution, preferential posterior flow of the solution, and difficult placement, all of which could affect the results following lumbar TLESI. Fluoroscopic imaging is strongly recommended, as injections without the use of fluoroscopic assistance may have a rate of erroneous needle placement in as high as 30% to 40% of cases. (5)

There have been a number of complications reported during the use of lumbar TLESI, such as infections (e.g., epidural abscess, meningitis, and discitis), epidural hematomas, seizures, transient blindness, hiccups, flushing, and gas emboli. Additionally, there are known side effects that are related to the use of steroids in the lumbar spine, such as pituitary suppression, osteonecrosis, osteoporosis, and weight gain, although these side effects are extremely rare when the recommended doses are used in the lumbar spine. (6) Most large series have no reported serious complications, however, and only case reports exist regarding these complications. Injections, therefore, are generally thought to carry a very low risk.

Lumbar TFESI

Lumbar TFESI has the benefit of being highly selective, especially in the treatment of lumbar radiculopathy, and it can be utilized in a diagnostic capacity in the preoperative patient to help identify symptomatic nerve roots. Fortunately, several high-quality randomized controlled trials regarding lumbar TFESI have been performed.

Kolsi and colleagues (7) conducted a prospective, randomized, double-blind study consisting of 30 patients with refractory nerve root pain. Patients were randomized to lumbar TFESI or insterspinous sham injection. They were followed for 4 months, and pain on a 0 to 100 scale was used as the primary outcome. Pain relief was similar in both groups, going from 70 to 26 in the group that received a nerve root injection and from 63 to 23 in the interspinous group. Notable limitations in this study included short follow-up, unknown number of injections, and crossover.

A prospective, randomized, controlled, double-blinded trial conducted by Riew and associates (8) supports the use of TFESI as a nonoperative modality that has the potential of avoiding surgery for lumbar radiculopathy. This study followed 55 patients who requested operative treatment with lumbar radicular pain (4 spine surgeons) with 13 to 28 month follow-up. Of these 55 patients, 9 of the 27 (33%) patients injected with bupivicaine alone decided to not have surgery while 20 of the 28 (71%) of patients injected with steroids decided to not have surgery (p < 0.004).

Additional studies have shown that lumbar TFESI injections have good short-term outcomes in the setting of lumbar disc herniation9 and spinal stenosis. (10) These studies all support the use of these injections, but these benefits must be weighed against the risk of complications.

Complication rates in studies have ranged from 0% to 1.9%. One serious event, retroperitoneal hematoma in a patient on anticoagulation treatment, was noted. Given the rarity of complications, there is no study to date with adequate power to detect the actual incidence of these problems. Several case reports exist of which the practitioner should be aware. Houten and Errico reported on a case series of three patients who suffered sudden paraplegia after lumbar (two patients) or sacral (one patient) nerve root block.11 The hypothesized mechanism was arterial injection into an anatomic variant of the artery of Adamkiewicz, which runs from T9-L2 in 85% of patients. In that study, one patient improved to 3-4/5 strength in both lower extremities, the second had no recovery at 8 month follow-up, and the third had no recovery at 5 year follow-up.

Other reported complications include infection, allergic reaction, and dural puncture. Suggested measures to reduce risk include monitoring patients for 15 to 20 minutes after their injections, the utilization of particulate free steroids, testing for intra-arterial injection with digital subtraction angiography, and preliminary injection of a local anesthetic. With good technique, serious complications can be minimized.

Cervical TLESI

Cervical radiculopathy is a relatively common problem facing the spinal surgeon, with an incidence of 83.2 per 100,000 people. (20) When initial nonoperative treatment fails, the treating physician can consider a cervical steroid injection. The use of cervical TLESI has been increasing. There are several studies that have investigated its use.

While most investigators have found improvement with cervical TLESI, Castagnera and associates (12) did not. They performed translaminar cervical injections in 34 patients. Fourteen patients received a steroid injection while 10 were injected with morphine. Similar outcomes were seen, as both groups had 79% to 80% success rate at one year.

Stav and coworkers (13) compared 25 patients with cervical TLESI to 17 patient with steroid injections into the posterior neck muscles. Results at 1 week demonstrated pain relief in 76% of patients injected with translaminar cervical epidural steroid compared to only 36% pain relief in patients injected in their deep neck muscles. Furthermore, significant differences were seen between these two groups at 1 year, with excellent pain relief in 68% of the TLESI group and only 12% of the deep neck muscles group.

Ferrante and colleagues (14) performed a retrospective review of 100 patients with cervical TLESI. They used multiple regression analysis to determine predictors of outcome after cervical TLESI. Of all the factors studied, radicular pain was highly predictive of a good outcome (p = 0.0004).

In a retrospective review of 45 cervical TLESI in 25 patients, Rowlingson and Kirschenbaum (15) studied patients who failed a long trial of nonoperative management. Sixty-four percent of these patients had a good or excellent long-term result, showing that cervical TLESI remains a viable option for patients in whom prolonged nonoperative treatment has remained ineffective.

Benyamin and associates (16) carried out an extensive review using the Cochrane Musculoskeletal Review Group criteria. They concluded that there is level II-1 (with a grade 1C "strong recommendation") evidence for the use of cervical TLESI for both chronic neck and upper extremity pain. Cervical TLESI is an excellent option that has the potential for long-term benefits, especially in patients with radiculopathy as opposed to isolated neck pain.

As in all types of epidural spinal injections, the benefits must be weighed against the risk of complications. Waldman and associates (17) in a prospective study of 790 blocks in 215 patients, found two dural punctures, two episodes of vasovagal syncope, and one late superficial infection. This study used only loss of resistance, not fluoroscopy, to localize the injections. In contrast, Botwin and coworkers (18) reported on a retrospective cohort analysis of 345 flouroscopically guided injections in 157 patients. A much higher overall complication rate of 26.8% was reported. These investigators noted increased neck pain in 6.7% of cases and headache for less than 24 hours in 4.6% of cases. Transient insomnia, vasovagal reactions, and facial flushing all occurred at a rate of under 2%. It is likely that the high overall rate of complications in this study was related to the sensitivity of labeling an event a "complication," as the mentioned complications were relatively safe and temporary.

However, there have been other reports of more serious complications. Epidural hematoma has been reported six times in the literature. Most occurrences were in patients who were also undergoing anticoagulation regimens. These patients generally went on to have laminectomies, and recovery ranged from full recovery to paraplegia, urinary retention, or long-term neck pain.

Dural punctures with reported rates ranging from 0.25% to 2.65% have been reported. Other severe reported complications include neuropathic syndromes, pneumocephalus (found with use of air for loss of resistance in one case), venous air embolism, cervical epidural abscess, Cushing's syndrome, and death (only one report in the literature; in this case, a spinal hematoma led to acute meningitis that ultimately resulted in a cardiac arrest).

Abbasi colleagues (19) conducted an extensive review on cervical TLESI. They reported that the consensus is that cervical TLESI is a safe procedure. While one study reported a complication rate of 16.8%, all of the complications were transient. Other studies reported lower complication rates. The incidence of vasovagal reactions, however, may be higher than for lumbar TLESI. Ultimately, while severe complications exist, they are rare and can be minimized by good technique.

Cervical TFESI

Use of a transforaminal approach can allow the practitioner to perform a diagnostic and therapeutic selective nerve root block to help identify the affected level and the success of selective decompression in the future, should it become necessary.

There are a limited number of reports in the literature regarding the efficacy of cervical TFESI, probably because these injections are performed less commonly due to concern about complications. In one study, Anderberg and coworkers (21) looked at 40 patients with cervical radiculopathy randomized to steroid and local anesthetic TFESI or saline with local anesthetic injections. No significant difference was found between the two groups.

There are also only a few studies regarding the complications of transforaminal cervical epidural steroid injections. Most of the reported incidents are case reports, and therefore the true incidence of these complications is not yet known. One study of 1,036 injections in 844 patients found an overall complication rate of 1.64%. (22) In that study, there were five headaches, six transient neurologic deficits (pain or weakness), one hypersensitivity reaction, one vasovagal reaction, and one incident of transient global amnesia. In another study, Slipman and colleagues found three dural punctures, one vasovagal bradycardic response, one allergic reaction to local anesthetic leading to unresponsiveness, two allergic responses to contrast, and one posterior interosseous syndrome in their series of 888 procedures.

While the complications in the study conducted by Ma and associates (22) were generally transient, others have reported much more serious adverse outcomes. For instance, Scanlon and coworkers (23) sent out 287 surveys to physicians and found 78 complications, of which 70 involved corticosteroids. Complications included 16 vertebrobasilar brain infarcts, 12 cervical spinal cord infarcts, and two combined brain and spinal cord infarcts. Additionally, there were five deaths of unspecified etiology, thee high spinal anesthesias, three transient ischemic attacks, two seizures, two severe headachse, two spinal cord edemas, one brainstem edema with herniation, one brain edema with reversible ischemic neurologic deficit, one cortical blindness due to air embolus, one cervical epidural hematoma, one paraspinal hematoma, one peripheral neurapraxia, and one vasovagal response. While this type of study likely includes a very large number of patients and does not allow us to know what the incidence of these injuries is, they are nevertheless serious complications and the practicing surgeon must be aware of the risks associated with this procedure.

Conclusion

There is good evidence that both transforaminal and translaminar epidural steroid injections can provide reliable pain relief for up to 6 months. In the lumbar spine, both TLESI and TFESI are relatively safe and efficacious. The exact complication rates of these injections are difficult to know given the existing literature but are thought to be low. In the cervical spine, there is good evidence to support TLESI, and reliable pain relief has been demonstrated at one year or longer in some studies. In contrast, cervical TFESI are used less often, and there is a paucity of literature evaluating these injections. There is to date no reliable studies demonstrating their efficacy, and there have been a number of potentially devastating complications reported. Since cervical radiculopathy can also be treated with TLESI, we urge caution before proceeding with cervical TFESI.

Disclosure Statement

The authors have no financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

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(2.) Arden NK, Price C, Reading I, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology (Oxford). 2005;44:1399-1406.

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(15.) Rowlingson JC, Kirschenbaum LP. Epidural analgesic techniques in the management of cervical pain. Anesth Analg. 1986;65:938-42.

(16.) Manchikanti L, Singh V, Pampati V, et al. Description of documentation in the management of chronic spinal pain. Pain Physician. 2009;12(4):E199-224.

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(18.) Botwin KP, Castellanos R, Rao S, et al. Complications of fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil. 2003;84(5):627-33.

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Joshua Landa, M.D., and Yong Kim, M.D., are in the Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Joshua Landa, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10016; joshua.landa@gmail.com.

Landa J, Kim Y. Outcomes of interlaminar and transforminal spinal injections. Bull NYU Hosp Jt Dis. 2012;70(1):6-10.
Table 1 Summary of Outcomes and Complications Regarding Spinal
Injections

                 Efficacy

Cervical TLESI   Good evidence to support relief to one year or longer
                 Minimal evidence to support efficacy

Lumbar TLESI     Good evidence to supports short term (< 6 months)
                 efficacy

Lumbar TFESI     Good evidence to supports short term (< 6 months)
                 efficacy

                 Complications

Cervical TLESI   Serious complications have been reported but are rare
                 Many serious complications have been reported, though
                 their true incidence is not known

Lumbar TLESI     Complication have been reported but are uncommon
                 and usually not serious

Lumbar TFESI     Serious complications including paraplegia have been
                 reported but are rare
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