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IntroductionIntravascular injection of a local anesthetic can lead to life-threatening complications, such as deficits in neurological function after caudal epidural block. This study aimed to determine whether the intravascular injection rate of the Tuohy needle is lower than that of the Quincke needle during an ultrasound-guided caudal block.MethodsTwo-hundred and thirty patients were randomized into the Quincke (n=115) and the Tuohy (n=115) needle groups. The randomly selected needle was introduced at a 45° angle until it penetrated the sacrococcygeal ligament under ultrasound guidance, and intravenous injections were analyzed using contrast-dyed digital subtraction angiography. The relationship between the incidence of intravascular injection and independent variables, including needle type, patient demographics, history of lumbosacral surgery, use of anticoagulants, anatomic variables of the sacrum, presence of bony contact during the procedure, and the number of needle repositioning under ultrasound guidance, were examined.ResultsIntravascular uptake of contrast medium was surveyed in 25/230 (10.9%) caudal blocks using digital subtraction angiography (DSA). The incidence of intravascular uptake was 13.9% (16/115) using the Quincke needle and 7.8% (9/115) using the Tuohy needle (p=0.14). Although the needle tip type was not associated with the rate of intravascular injection, the occurrence of bony contact during the procedure demonstrated a relationship with the intravenous injection (p<0.01).ConclusionsThe overall incidence of inadvertent intravascular injections during ultrasound-guided caudal block confirmed using DSA was 10.9%. Tuohy needles did not reduce intravascular injection rates during the ultrasound-guided caudal block.Trial registration number NCT05504590.

Cervical interlaminar epidural injections are usually performed with the loss-of-resistance (LOR) technique. Therefore, no studies have evaluated or compared the hanging drop (HD) technique with the LOR technique in the administration of cervical interlaminar epidural injections (ILESIs). This study aimed to evaluate the success of the HD technique when used with the LOR technique in cervical ILESIs. A prospective, randomized trial. Department of Pain Medicine, Ege Hospital, Baku, Azerbaijan. After obtaining ethical committee approval and initiating a randomization process, we allocated patients diagnosed with cervical herniated nucleus pulposus (CHNP) into LOR- and HD-method groups. The LOR group comprised 38 patients, and the HD group comprised 41 patients. All patients underwent interlaminar epidural steroid injections under C-arm fluoroscopy in contralateral oblique (CLO) safety view with an initial start angle of approximately 60 degrees. For the LOR group, the procedure was considered successful if there was a loss of pressure after slightly crossing the ventral spinolaminar line (VSLL) and the administered contrast material was in the epidural space. The procedure was considered successful if the saline in the needle's hub fell with negative pressure after slightly passing the VSLL and if the contrast administered was seen in the epidural space with fluoroscopy. In the HD group, there was no sensation of a drop in 3 patients, and the procedure was completed with LOR, so these patients were excluded from the study. Complications and pain scores on the VAS (visual analog scale) were questioned at the time of the procedure and at one hour and 3 weeks after the procedure, and successful injection ratios were recorded. The LOR and HD groups were similar in age, gender, body mass index (BMI), and side of ILESI. The successful injection ratio was higher in the right- and left-sided ILESI group than in the median ILESI group (P < 0.01). Therefore, no differences were found between the right and left ILESI groups. Binary logistic regression analysis found that age, gender, and BMI were not associated with successful injection in the HD group, while medial injection was associated with decreased successful injection risk (OR: 0.068, P = 0.034). The successful injection ratio was higher in the LOR group than in the HD group (P < 0.001). The study's limitations include the relatively small number of patients with CHNP  and the lack of mention of the level of CHNP. The LOR technique was superior to the HD for cervical ILESIs. More studies with larger sample sizes may provide more precise and detailed information.

Epidural steroid injections (ESIs) are commonly used for management of lumbosacral radicular pain. Midline interlaminar (MIL) or transforaminal (TF) routes are commonly used. The TF route, although associated with higher delivery of drug to the ventral epidural space, has serious complications including spinal cord injury and permanent paralysis reported in literature. Therefore, there is a search for a technically better route with fewer complications and greater drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach has been defined. We conducted this study to compare therapeutic effectiveness of 3 techniques of ESIs in patients having unilateral lumbar radiculopathy. Further, effect of ESI on bone mineral density (BMD) and serum osteocalcin levels were studied. Randomized double-blind trial. Pain clinic of a tertiary care hospital. Sixty-five patients were randomly allocated into group MIL, group PIL, and group TF to receive epidural injection with 80 mg of methylprednisolone and 2 mL of 2% lidocaine. Effective pain relief and improvement in disability were assessed using Visual Analog Scale (VAS) and Modified Oswestry Disability Questionnaire (MODQ) scores at 2 weeks, 4 weeks, 3 months, and 6 months, respectively. Patients with < 50% relief received additional injection. Primary outcome of study was effective pain relief at 6 months. Mean change in VAS and MODQ scores, BMD, and serum osteocalcin levels were secondary outcome assessed. Patients having effective pain relief were significantly higher in group PIL (16 of 20 [80%]) and group TF (15 of 20 [75%]) compared with group MIL. Patients receiving ESI in group PIL and group TF showed significantly lower VAS scores than group MIL (P = 0.02, P = 0.50 at 3 months and P = 0.00, P = 0.02 at 6 months, respectively). Mean MODQ scores in group PIL and group TF were significantly lower than group MIL. However, group PIL and group TF did not significantly differ in MODQ scores. There was no significant change in serum osteocalcin and BMD, as assessed by dual energy x-ray absorptiometry scan at 3 months. The absence of a placebo control group, small sample size, and relatively short follow-up of 6 months were limitations. PIL approach is equivalent to TF and superior to MIL approach in terms of effective pain relief and decrease in disability in patients with unilateral lumbar radiculopathy. This study showed no deleterious effect on BMD. Epidural steroid, technique, efficacy, bone marrow density, serum osteocalcin.

Cervical transforaminal epidural block (CTEB) is a useful option in the diagnosis and treatment of cervical radicular pain. However, inadvertent intravascular injection can lead to severe neurologic complications. Blunt needles are considered to displace instead of penetrate vessels because of their dull needle tip. To investigate whether there is a difference between blunt and sharp needles in intravascular injection rates during CTEB. Prospective, randomized, clinical trial. A tertiary hospital in South Korea. After institutional review board approval, 108 patients undergoing CTEB for treatment of radicular pain resulting from spinal stenosis and herniated nucleus pulposus were randomly assigned to one of 2 needle groups (blunt needle or sharp needle). The needle position was confirmed using biplanar fluoroscopy, and 2 mL of nonionic contrast medium was injected to detect intravascular injection. Intravascular injection was defined as the contrast medium spreading out through the vascular channel during injection under real-time fluoroscopy. This study was registered in ClinicalTrials.gov. The intravascular injection rate was not significantly different between the blunt needle and sharp needle groups (35.2% vs. 33.3%, P > 0.05). The procedure time was longer in the blunt needle group than in the sharp needle group (101.00 ± 12.4 seconds vs. 56.67 ± 8.3 seconds, P < 0.001). This was a single-center study. Additionally, the physicians could not be blinded to the type of needle used. In the present study, use of a blunt needle did not reduce the rate of intravascular injection during CTEB compared to use of a sharp needle. In addition, procedure time significantly increased with blunt needle use compared to sharp needle use. Analgesia, bleeding, blunt needle, cervical spine, clinical trials, complications, intravascular injection, radiculopathy, sharp needle, transforaminal epidural block.

BACKGROUND: Informed consent is a crucial ethical and legal requirement in medical practice to ensure that patients understand the risks, benefits, and alternatives of medical procedures. Recent advances in multimedia technology have facilitated the exploration of multimedia consent, aiming to enhance patient understanding and satisfaction. Ascertaining that patients have full comprehension of the procedures before opting to undergo them is especially important now that instances of such procedures as lumbar transforaminal epidural steroid injections (TESIs) are increasing. OBJECTIVES: To determine the effectiveness of multimedia consent forms for lumbar transforaminal steroid injections. STUDY DESIGN: Randomized clinical trial. SETTING: Outpatient multidisciplinary pain medicine center of a tertiary hospital. METHODS: A randomized controlled trial was conducted with 30 patients who received lumbar TESIs for lumbar radiculopathy. Patients were randomly assigned to either the multimedia consent group (Group M) or the conventional paper consent group (Group C). This study evaluated patients’ comprehension of the procedure, their anxiety levels (using the State-Trait Anxiety Inventory short form), and the patients’ post-procedure satisfaction. RESULTS: Group M showed significantly greater understanding of the procedure and reported lower levels of anxiety than did Group C (P = 0.041; P = 0.03). However, there were no statistically significant differences in post-procedure satisfaction between the groups (P = 0.25). These findings suggest that multimedia consent can effectively improve patient comprehension and reduce anxiety without significantly affecting patient satisfaction. LIMITATIONS: First, the limited sample size of 30 patients restricts the applicability of our findings to a wider population, suggesting a need for larger studies to better assess the effects of multimedia consent. Second, conducting the study in a single hospital might have introduced bias. Multicenter research may provide a more diverse and accurate evaluation of the efficacy of multimedia consent. CONCLUSION: This pilot study contributes to the growing evidence supporting the use of multimedia consent to enhance patient understanding and reduce anxiety, marking a promising direction for improving informed consent practices for less invasive procedures, such as lumbar TESIs. Further research is required to fully explore the benefits and limitations of multimedia consent forms in various medical settings. KEY WORDS: Multimedia, informed consent, video consent, alternative consent form, paper consent, transforaminal epidural steroid injection, pre-procedure anxiety, patient comprehension

Epidural fibrosis (EF) is one of the leading causes of post lumbar surgery syndrome (PLSS). Although there are studies in the literature suggesting that lumbar epidural steroid injections are an effective method in the pain management of PLSS caused by EF, no study is available comparing the effectiveness and safety of caudal and transforaminal approaches. To investigate the efficacy of caudal epidural steroid injection (CESI) versus transforaminal epidural steroid injection (TFESI) in patients with PLSS. A prospective, randomized, assessor-blind study. Interventional pain management center at a tertiary care center. Patients with low back and radicular pain related to EF following single-level lumbar discectomy were included. The patients were randomly divided into 2 groups: a CESI group and a TFESI group. All patients were assessed before the procedure (baseline) and at one hour, 3 weeks, and 3 months after the procedure using the Numeric Rating Scale (NRS-11) and at baseline, 3 weeks, and 3 months using the modified Oswestry Disability Index (mODI). Treatment success was defined as a >= 50% decrease in the NRS-11 scores compared to baseline. A total of 56 patients (n = 26 CESI group; n = 30 TFESI group) were included. NRS-11 and mODI scores showed a significant decline in both groups at all follow-ups (P < 0.001). At 3 weeks, the improvement in the mODI scores was significantly higher in the TFESI group (P = 0.020). In all follow-ups, the NRS-11 scores were similar between the groups. At 3 weeks, the rates of patients with a >= 50% decrease in NRS-11 scores were 53.8% and 60% in the CESI group and TFESI group, respectively, while these rates were 30% and 26.7%, respectively, at 3 months. This study had no placebo-control group and a relatively short follow-up. Both CESI and TFESI are effective and safe methods in the treatment of PLSS caused by EF following lumbar discectomy. These methods can reduce pain and disability. Although both methods have similar treatment success rates, TFESI seems to be a more effective treatment method in reducing disability at 3-week follow-up.

Background: The estimated prevalence of lumbar radiculopathy has been described as 9.8 per 1,000 cases of low back pain. There are various surgical and nonsurgical modalities for treating lumbar disc herniation or radicular pain, including epidural injections. Epidural injection administration routes include transforaminal, interlaminar, and caudal approaches. The transforaminal approach requires the smallest volume to reach the primary site of pathology. Systematic reviews have yielded highly variable results, but a recent systematic review showed no significant difference among the 3 approaches. Study Design: A randomized, controlled, double blind, active control trial. Setting: An interventional pain management practice, a private specialty referral center in the United States. Objectives: To assess the effectiveness of transforaminal epidural injections of local anesthetic with or without steroids in managing chronic low back and lower extremity pain in patients with disc herniation and radiculitis. Methods: One hundred twenty patients were randomly assigned to 2 groups: Group I received 1.5 mL of 1% preservative-free lidocaine, followed by 0.5 mL of sodium chloride solution. Group II received 1% lidocaine, followed by 3 mg, or 0.5 mL of betamethasone. The sodium chloride solution and betamethasone were either clear liquids or were provided in opaquecovered syringes. Outcomes Assessment: The primary outcome measure was significant improvement (at least 50%) measured by the average Numeric Rating Scale (NRS) and the Oswestry Disability Index 2.0 (ODI). Secondary outcome measures were employment status and opioid intake. Results: At 2 years there was significant improvement in all participants in 65% who received local anesthetic alone and 57% who received local anesthetic and steroid. When separated into non-responsive and responsive categories based on initial relief of at least 3 weeks with 2 procedures, significant improvement (at least 50% improvement in pain and function) was seen in 80% in the local anesthetic group and 73% in the local anesthetic with steroid group. Limitations: Presumed limitations of this evaluation include the lack of a placebo group. Conclusion: Transforaminal epidural injections of local anesthetic with or without steroids might be an effective therapy for patients with disc herniation or radiculitis. The present evidence illustrates the lack of superiority of steroids compared with local anesthetic at 2-year follow-up. Key words: Chronic low back pain, transforaminal epidural injections, disc herniation, radiculitis, lower extremity pain, local anesthetic, steroids

BACKGROUND: Although there are studies evaluating ultrasound-guided selective nerve root pulsed radiofrequency (ULSD-SNRPRF) and fluoroscopy-guided paramedian cervical interlaminar epidural steroid injection (FL-CIESI) for the treatment of chronic cervical radicular pain, no study has compared the efficacy of these 2 methods. OBJECTIVES: This study aimed to compare the efficacy of these 2 methods, their superiority to each other, and the incidence of adverse events. STUDY DESIGN: A prospective, randomized controlled trial SETTING: Outpatient department of a single-center pain clinic. METHODS: Sixty patients who did not respond to conservative treatments for lower cervical radicular pain were randomly divided into 2 groups. One group underwent ULSD-SNRPRF (Group U), and the other underwent paramedian FL-CIESI (Group F). Patients were evaluated pretreatment, and 3 and 6 months posttreatment. The Numeric Rating Scale (NRS-11) was used to assess clinical improvement, The Neck Disability Index (NDI) to assess improvement in functional disability, and the Self-Leeds Assessment of Neuropathic Symptoms and Signs Pain Score (S-LANSS) to assess the treatment’s effect on neuropathic pain. Clinically significant pain relief was defined as a 50% or more pain reduction in the NRS-11. The posttreatment reduction in medication consumption was assessed using the Medication Quantification Scale Version III (MQS III). We also evaluated whether there was a difference in treatment-related characteristics, such as procedure time and adverse events. RESULTS: The procedure time was significantly longer in Group U. Blood aspiration was observed in 2 patients in Group U and vascular spread in one patient in Group F, with no significant difference. At 3 and 6 months posttreatment, NRS-11 and NDI scores showed a significant decrease compared to the pretreatment scores in both groups; there was no difference between the groups. Both treatments effectively improved neuropathic pain, with no significant difference between the S-LANSS scores. There was no difference in the reduction of medication consumption between the groups. LIMITATIONS: There was no sham or control group, and the follow-up period was limited to 6 months. CONCLUSIONS: Pain relief, functional improvement, and safety were similar between groups. ULSD-SNRPRF and paramedian FL-CIESI are 2 different effective techniques for chronic cervical radicular pain. The choice of method should depend on various factors, such as patient preference, operator experience, and availability of resources. An advantage of ULSD over fluoroscopy is that patients and physicians are not exposed to radiation. KEY WORDS: Pulsed radiofrequency treatment, epidural injections, steroids, radiculopathy, neck pain, fluoroscopy, ligamentum flavum, ultrasonography

Lumbar transforaminal epidural injection (TFEI) effectively decreases low back pain and radicular pain in herniated intervertebral disc (HIVD) and spinal stenosis (SS). The precise delivery of drugs to the target is important for pain control and minimizing complications. We aimed to evaluate the efficacy and complications of the subpedicular (SP) and retrodiscal (RD) approaches by analysis of contrast spread patterns into the pathologic target on the basis of a newly established specific criterion. We also investigated whether the severity of patients' spinal disease influenced this pattern. A prospective, randomized, observational study. Interventional pain management center at a university-affiliated hospital. Among patients who showed lumbar spinal stenosis or HIVD at the L4/5 level, participants were randomly assigned to undergo TFEI with the SP approach (SP group) or RD approach (RD group). Pain relief in terms of the visual analog scale (VAS) score and complications such as intravascular or intradiscal uptake were also analyzed. The contrast image was analyzed as the contrast media was injected, starting from 0.5 mL up to 3.0 mL. The spread patterns of contrast media were graded into 4 categories, which were newly defined in this study. Both groups demonstrated a significant decrease in pain relief (P value < 0.01) at 2 and 4 weeks after the procedures, but no significant difference was found between the 2 groups. In the intergroup analysis between the RD and SP groups, with a 1.5-mL contrast media injection, more patients in the RD group (17.2%) showed a grade 3 spread than those in the SP group (8.2%). In the subgroup analysis, the RD group showed superior spread (more grade 3 and 4) with 1.5-, 2-, and 2.5-mL contrast media injections (P values = 0.02, 0.03, and 0.04) in severe central stenosis, and 1.5- and 2-mL contrast media injections (P values = 0.01, 0.02) in severe foraminal stenosis. The follow-up period was only 4 weeks after TFESI, and higher contrast injection was used for procedures. The RD approach for TFEI showed a better contrast spreading pattern than the SP approach, especially in patients with severe central and foraminal spinal stenosis. The RD approach might be more beneficial for patients with severe central and foraminal spinal stenosis in the short-term follow-up.