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Use of CT-guided periradicular injection for the treatment of foraminal and extraforaminal disc herniations

Study design: Retrospective case series. Evidence level IV. Objectives: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option for avoiding surgery. Methods: We carried out a retrospective evaluation of 46 consecutive patients with foraminal or extraforaminal disc herniation treated with CTGPI. CTGPI was performed only when radicular pain could not be controlled, or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years. Results: At 1 month after injection, 41 (89%) patients experienced a decrease in radicular pain; 3 experienced no change; and 2 had received surgical treatment. At the final follow-up visit (mean, 74 months) 6 additional patients underwent surgery while 38 (83%) did not require surgery. Pain level comparison between pre-injection and last examination showed that low back pain had decreased a mean of 5 points and radicular pain diminished a mean of 7 points. Twenty-two (58%) of the 38 nonoperated patients had no pain at all and 35 patients had resumed their normal daily activities. No complications were recorded. Conclusion: Based on these results, we consider that the use of CTGPI is a reliable alternative before surgery for patients with foraminal or extraforaminal disc herniation without severe motor deficit but with intractable radicular pain. Final Class of evidence (CoE)-treatment Yes Study design: RCT Cohort Case control Case series • Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome F/U ≥85% • Adequate sample size • Control for confounding Overall class of evidence IV The definiton of the different classes of evidence is available on page 59.

Original research-Use of CT-guided periradicular injection for the treatment (…) • All patients have at least 2 years of follow-up. • Before the periradicular injection, all patients underwent a complete trial of conventional medical therapy including bed rest, physiotherapy, antiinflammatory drugs, and analgesics. • CTGPI was performed only when radicular pain could not be controlled or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. • Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years (range, 19-73) ( Table 1). • Mean follow-up of 6 years. • Sixty-one CTGPI were performed on 46 patients (1 injection, 34 patients; 2 injections, 9 patients; and 3 injections, 3 patients).

Outcomes:
• We reviewed the ambulatory digital medical records to collect data on previous treatments, pain intensity at the time of the injection, and at the first postinjection follow-up 4 weeks after the procedure, or if the patient had had surgery. • As microdiscectomy was considered a failure of CTGPI, the patients were not evaluated further following surgery regardless of the surgical result. • Radicular and low back pain were independently evaluated according to the visual analogue scale (VAS), graded from 0 (no pain) to 10 (maximum pain ever suffered). • We also documented whether the procedure had been painful and how many days later the decrease in pain was noticed and possible complications. • For the final follow-up evaluation at time of the study review, all patients were contacted by a physician not directly involved in their treatment ( Table 3). Patients gave oral consent but not written consent for the study. • We also documented when the patient was able to resume work and sports activities. • In all cases, the diagnosis of foraminal or extraforaminal disc herniation was performed by magnetic resonance imaging according to Mc Culloch [1].

Analysis:
• The statistical analysis utilized for VAS values was the Wilcoxon signed rank test for paired samples.
Additional methodological and technical details are provided in the web appendix at www.aospine.org/ebsj.

STUDY RATIONALE
Peridural steroid injections appear as a treatment of unreliable result. Most patients with lumbar radicular compressions received surgical treatment as the last treatment option for the management of severe sciatica or cruralgia resistant to conservative therapy. Many patients would be able to avoid surgery if these symptoms could be controlled with a conservative treatment.
We believe that peridural injections could be a good treatment option to avoid surgery.

OBJECTIVES
The purpose of this study is to evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option to avoid surgery.

Strengths:
• We only evaluated lateral herniation.
• Our cohort was assembled from a community clinical practice, making it likely that our results are broadly generalizable.

Limitations:
• Relatively small number of patients included.
• Retrospective study without a control group. However, our results are comparable with other studies that are prospective [5]. • In the two most frequently cited prospective randomized double-blinded studies, diverse results are reported. • After reviewing the available literature, it becomes obvious that there are no perfect protocols to show the efficacy of nerve root injection (NRI). Even surgical candidates in control groups avoid surgery in 33%-48%. • Karppinen et al [6] found significant differences on almost every parameter between the study group (bupivacaine plus methylprednisolone) and the control group (saline) only at the 2-week follow-up. This implies that the procedure only brings short-term clinical benefit. However, 23% of their population has normal or bulging discs, which we consider not surgical candidates in our practice. • Riew et al [7] found that in their study group most patients with lumbar radicular pain who avoid an operation for at least 1 year continue to avoid operative intervention for a minimum of 5 years.

Clinical relevance and impact
• The natural history in patients with sciatica caused by a disc herniation is favorable [8][9][10][11][12][13][14], which explains why the effectiveness of CTGPI or any other procedure is difficult to establish. • Epidural steroid infiltration under image intensifier guidance is not a new procedure and has been performed for more than 35 years [15]. However, its effectiveness is still controversial; while some reports demonstrate it as a useful alternative [8,16,17], others only compare its action with that of intramuscular administration or with the natural history of the disease [18][19][20]. • The use of CT guidance can make the procedure more expensive, and most clinicians support the use of image intensifier. In our institution, one of five CT scanners is assigned only to invasive percutaneous procedures and is usually available for scheduling a 10-minute CTGPI. Despite the increased initial costs of CT, it may lead to financial savings in comparison with image-intensifier guided operating-room CTGPI as is performed in many institutions; additionally, the image is biplanar instead of monoplanar and is more accurate.

DISCUSSION
• We first reported our results with CTGPI in 1996 [2]; our impression was that this procedure was effective for the management of patients with severe radicular pain due to disc herniation. • We included only patients with foraminal or extraforaminal disc herniation because the natural history of disc herniation in this location is less favorable [3,4] • Of 46 patients, who were all deemed surgical candidates, 8 (17%) were finally operated. • Among 38 patients who did not require surgical treatment, 28 (74%) improved within the first 15 days. These findings, in patients who had gone through several weeks of pain and multiple treatments, make it unlikely that pain improvement had followed the natural history of the disease (6-12 months). • The documented pain score difference before CTGPI and at final follow-up as expressed with a visual analogue score seems to recall the natural evolution of disc herniation.

Evidence-Based Spine-Care Journal
Original research-Use of CT-guided periradicular injection for the treatment (…)

SUMMARY AND CONCLUSIONS
Based on our results, we consider that the use of CT-guided periradicular infiltration is a safe and reliable alternative for patients with foraminal or extraforaminal disc herniation without severe motor deficit that remain with intractable radicular pain after adequate conservative treatment.

EDITORIAL PERSPECTIVE
The reviewers congratulate the authors on taking on this contentious topic of managing lumbar disc herniation with nonsurgical care and openly discussing the shortcomings (retrospective, absence of comparison group, reliance on a single score only -VAS, no ODI, EQ-5D,  [4]. The variability of physician behaviors, range of responses, and individuality of care will inevitably clash with insights gained through review of larger patient databases, such as collected in registries.
For now, this study suggests that a well-performed foraminal epidural steroid injection is a treatment option for patients with radicular symptoms. When considering future studies involving epidural steroid injections the possibility of including CT-based confirmation of periradicular needle location for patients with selected pathology certainly would seem to be a worthwhile consideration.