Cumulative Project

Cumulative Project

Case Overview

A 37-year-old, right-handed woman presents with complaints of severe left upper chronic back pain that has been ongoing for three months. Her pain radiates down the posterior arm and forearm. She does not have progressive weakness, gait dysfunction, loss of dexterity, or bowel or bladder dysfunction. She has been managed with medications and physical therapy but continues to have severe pain that is functionally limiting.

Physical examination shows full strength in upper limbs but there is a decrease in light touch and pinprick over the dorsum of the third finger. Muscle stretch reflex at the left triceps is decreased compared to the right. Upper motor neuron signs are negative. Neural tension signs reproduce left upper limb pain. MRI is obtained and noted below. The plan is to proceed with a cervical epidural injection.

Several questions arise when doing this injection. What type of steroid should be used in the epidural injection based on safety and efficacy? Does the approach of a transforaminal versus interlaminar injection make a difference when selecting a steroid? What would be the considerations if this was a lumbar injection?

Figure 1. T2 axial MRI showing foraminal narrowing at the C6-7 level

Transforaminal Approach

Considerable advances have been made in the pharmacotherapy of neuropathic pain. However, many patients obtain only partial pain relief, or experience intolerable adverse effects with medications. Interventional treatments are often used in such patients. The long-term benefits of these treatment strategies, however, have been less well studied. Chronic low back pain with radiculopathy is a common indication for local anesthetic nerve blocks with or without steroids. This presentation will provide an evidence-based review of the literature on the role of epidural steroid injections in the management of radicular pain. Epidural steroids have been administered using various (Tiso, 2004)

Interlaminar, Transforaminal, and Caudal Routes, and at varying sites along the neuraxis. A recent systematic review reported that eight of 11 RCTs using lumbar interlaminar epidural injections of steroids (methylprednisolone or triamcinolone) with or without local anesthetic reported short-term (< 6 week) benefits on pain. However, only two of these studies demonstrated any long-term benefit. These studies suggest grade B and C recommendation for shortand long-term reduction in pain with lumbar interlaminar epidural steroid injection, respectively. The interlaminar epidural steroid injection can miss the targeted ventral epidural space in up to 40% of cases. A transforaminal approach has been advocated based on the observation that the injectate spreads to the ventral epidural space in almost all cases. Four of seven studies report a short- (6 weeks or less) and long-term benefit from these nerve blocks. Two of the RCTs compared the effects of transforaminal with interlaminar epidural steroid injections (Somyaji, 2005). The positive studies report that the transforaminal epidural steroid injections were associated with improvements in pain and quality of life outcomes during mean follow-up periods of 6-8 months (grade B) whereas the negative studies suggest that a single injection may not consistently provide beneficial effects. A few studies have examined the efficacy of radiofrequency (RF) lesioning ...