SPINE Volume 40, Number 10, pp 719-724 ©2015, Wolters Kluwer Health, Inc. All rights reserved.

CLINICAL CASE SERIES

Ventral Epidural Filling Technique in Interlaminar Epidural Steroid Injection Chang-Hoon Jeon, MD, PhD,*† Yu-Sang Lee, MD,*† Han-Dong Lee, MD,*† and Nam-Su Chung, MD*†

Study Design. A retrospective case-control study. Objective. To evaluate the safety and efficacy of the ventral epidural filling technique in lumbar interlaminar epidural steroid injection (ESI). Summary of Background Data. The ventral epidural space can be a preferred target in ESI because it contains many spinal pain generators. However, there have been few studies regarding the ventral epidural space filling technique in interlaminar ESI. Methods. This study involved a retrospective analysis of 150 consecutive patients treated with the ventral epidural filling technique in interlaminar ESI (ventral ESI) and a control cohort of 150 consecutive patients treated with the dorsal epidural filling technique in interlaminar ESI (conventional ESI). The visual analogue scale for leg pain, the visual analogue scale for back pain, and the Oswestry Disability Index were compared at preinjection and 2 weeks, 6 weeks, 6 months, and 1 year postinjection. The groups were compared with regard to repeated injection or surgery within 1 year after the initial procedure. The fluoroscopic time and the procedure-related complications including severe pain (visual analogue scale score >7) during injection, dural puncture (subdural contrast spread), headache, neurological symptoms, and infection were also compared. Results. There were no significant differences in leg pain, back pain, or Oswestry Disability Index improvement at each visit between the ventral ESI group and the conventional ESI group (all P > 0.05). The numbers of repeat injections and surgical procedures were not significantly different between 2 groups (P = 0.262 and 0.385, respectively). There were no significant differences in severe pain at injection (P = 0.326), dural puncture (P = 0.428), headache

From the *Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea; and †Department of Orthopaedic Surgery, Bumin Hospital, Busan, Republic of Korea. Acknowledgment date: July 29, 2014. First revision date: December 18, 2014. First revision date: January 19, 2015. Acceptance date: February 10, 2015. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No relevant financial activities outside the submitted work. Address correspondence and reprint requests to Nam-Su Chung, MD, Department of Orthopaedic Surgery, Ajou University School of Medicine, San 5 Wonchon-dong, Youngtong-gu, Suwon, Kyounggi-do, Korea; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000833 Spine

(P = 0.393), neurological symptom (P = 0.419), or infection (P = 0.500) between the 2 groups. The fluoroscopic time was significantly shorter in ventral than in conventional ESI (P < 0.000). Conclusion. The ventral epidural filling technique can be performed safely and more easily during lumbar interlaminar ESI. The clinical results and procedure-related complications with this technique were comparable with those seen with conventional interlaminar ESI. Key words: epidural steroid injection, interlaminar, ventral epidural space, peridural membrane, complication. Level of Evidence: 3 Spine 2015;40:719–724

A

lthough a recent meta-analysis demonstrated only short-term relief of pain and disability with small size of treatment effects in lumbar epidural steroid injection (ESI), it remains a useful nonsurgical management option in the management of radicular symptoms.1 In conventional interlaminar ESI, the needle tip is placed into the dorsal epidural space between the ligamentum flavum and the dural sac. Although the “loss-of-resistance” technique is used to verify the dorsal epidural space, the correct placement of the needle tip is often difficult because the space is quite narrow, especially in patients with spondylosis.2 Inadvertent dural puncture with instillation of the injectate into the subdural space occurs frequently. We postulated that placement of the needle tip into the ventral epidural space could be performed more easily because it is bound anteriorly by more solid structures, including vertebrae or intervertebral discs. Moreover, spinal pain generators are mostly located in the ventral epidural space, which is enclosed by the peridural membrane.3–5 Thus, the ventral epidural space can be a preferred target to fill and distribute the injectate. However, ventral epidural filling is limited in conventional interlaminar ESI.6 Choi and Barbella7 recently reported the targeted ventral epidural filling technique in interlaminar ESI. In their series, the dispersal patterns of the contrast medium showed excellent filling of the ventral epidural space with no neural complications. They reported that the ventral epidural filling technique in interlaminar ESI can be more effective and easier to perform, allowing the needle to be placed safely without risk www.spinejournal.com

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Ventral Epidural Filling Technique in Interlaminar Epidural Steroid Injection • Jeon et al

Figure 1. Transdural ventral filling technique in interlaminar ESI. A, The target point was determined as the lateral-most part of the interlaminar space on anteroposterior C-arm fluoroscopic images. B, A 25-gauge, 5-inch spinal needle was gently advanced until it touched the vertebral body or intervertebral disc. C, Nonionic contrast medium was injected to confirm the accurate placement of the needle tip into the ventral epidural space.

of neural injury. We have been performing a modified ventral epidural filling technique in interlaminar ESI since June 2011. The aim of this study was to evaluate the clinical and technical effectiveness of the ventral epidural filling technique in interlaminar ESI in comparison with conventional interlaminar ESI.

MATERIALS AND METHODS Study Subjects This study involved a retrospective analysis of 150 consecutive patients treated with the ventral epidural filling technique in interlaminar ESI (ventral ESI group), compared with a control cohort of 150 consecutive patients treated with dorsal epidural filling technique in interlaminar ESI (conventional ESI group). All of the patients included in the study had a clinical follow-up period of more than 1 year. The former were recruited between June 2011 and October 2012 and the latter between January 2010 and May 2011 through the department of orthopedic surgery in a tertiary hospital. The common indications of ESI in both groups were (1) lumbar radiculopathy, (2) availability of recent magnetic resonance imaging results corresponding to the patient's clinical symptoms, and (3) failure of noninvasive treatments to ameliorate the symptoms. Patients who had undergone lumbar spine surgical procedures or received ESIs in the previous 6 months were excluded. Patients with absolute surgical indications, including cauda equina syndrome and progressive neurological deficit, were also excluded. The ethics committee of the hospital reviewed and approved the present study.

Transdural Ventral Filling Technique in Interlaminar ESI All injections were administered in an ambulatory surgery center by a single spinal surgeon (N.C.) experienced in the procedure. The participant was placed in the prone position with a pillow under the abdomen. After preparing and draping the patient, the lateral-most part of the interlaminar space was 720

identified and marked on anteroposterior C-arm fluoroscopic images (Figure 1A). The skin and tissue overlying the target point were infiltrated with 1% lidocaine. A 25-gauge, 5-inch spinal needle was placed into the dorsal epidural space using the loss-of-resistance technique (conventional ESI technique). The needle was then gently advanced until it touched the vertebral body or the intervertebral disc. A lateral fluoroscopic view was obtained to ensure that the needle tip was placed behind the vertebral body or the intervertebral disc (Figure 1B). Nonionic contrast medium (iopamidol) was injected to confirm ventral epidural filling (Figure 1C). Once epidural placement was confirmed, 1.2 mL of 40 mg/mL triamcinolone diacetate and 0.4 mL of 0.5% bupivacaine (1.6 mL total volume) were injected.

Outcome Analysis Demographic data on each group, including age, sex, body mass index, smoking habits, diagnosis, duration of pain, injection level, and current oral medications (none, nonsteroidal anti-inflammatory drugs, paracetamol, or opioid), were obtained from the medical records. Visual analogue scale (VAS) for leg pain, VAS for back pain, and the Oswestry Disability Index were compared at preinjection and 1 month, 6 months, and 1 year postinjection. Further ESI and spinal surgery within 1 year after the initial procedure were compared between the groups. The fluoroscopic time and procedure-related complications, including severe pain (VAS score >7) during injection, dural puncture (subdural spread of the contrast medium), headache, neurological symptoms, and infection, were also compared. Other procedure-related complications during the ventral ESI, including vascular puncture (vascular spread of contrast medium) and disc puncture (intradiscal spread of contrast medium), were examined.

Statistical Analysis Descriptive statistics are represented as frequencies and percentages for categorical variables and as means and standard

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Ventral Epidural Filling Technique in Interlaminar Epidural Steroid Injection • Jeon et al

deviations for continuous variables. A Student t test, a χ2 test, and Mann-Whitney U test were used to compare each demographic and outcome parameter between the 2 groups. Statistical analysis was carried out using SPSS version 12.0 software (SPSS Inc., Chicago, IL). A P value of less than 0.05 was considered to indicate statistical significance.

RESULTS Demographics of the Study Participants

The mean age of the patients was 61.9 ± 16.0 years (range, 17–88 yr) in the ventral ESI group and 58.7 ± 17.1 years (range, 19–86 yr) in the conventional ESI group (P = 0.093). There were 83 (55.3%) males in the ventral ESI group and 67 (44.7%) males in the conventional ESI group (P = 0.454). There were no differences in body mass index (P = 0.313), smoking (P = 0.153), distribution of diagnosis (P = 0.384), duration of pain (P = 0.425), injection level (P = 0.538), or oral medication (P = 0.562) between the 2 groups (Table 1).

Improvement of Pain and Disability Table 2 shows the comparative analysis of pain and disability between the 2 groups. There were no statistically significant

differences in VAS for leg pain, VAS for back pain, or Oswestry Disability Index improvement at each visit between the ventral and conventional ESI groups (all P > 0.05). Significant improvements of VAS for leg pain between each visit (all P < 0.000) and VAS for back pain between each visit (all P < 0.000) were maintained until 1 year postinjection in both ventral and conventional ESI groups. Significant improvement of Oswestry Disability Index was maintained until 6 months postinjection in both ventral and conventional ESI groups (all P < 0.000).

Further Treatment, Fluoroscopic Time, and ProcedureRelated Complications The number of repeat injections and surgery were not significantly different between the 2 groups (P = 0.262 and 0.385, respectively). The mean fluoroscopic time was 9.8 ± 7.3 seconds (range, 5.0–35.5 s) in ventral ESI group and 17.1 ± 11.4 seconds (range, 8.5–32.6 s) in conventional ESI group (P < 0.000). There were no significant differences in severe pain at injection (P = 0.326), dural puncture (P = 0.428), or headache (P = 0.393) between the 2 groups. The only neurological complication was transient numbness, which occurred in 12 cases in the ventral ESI group and

TABLE 1. Demographics of Ventral ESI and Conventional ESI Variables N Age Male sex BMI (m/kg2) Smoking

Conventional ESI

150

150

61.9 ± 16.0

58.7 ± 17.1

0.093

83 (55.3)

67 (44.7)

0.454

24.4 ± 3.5

23.7 ± 2.5

0.313

46 (30.7)

37 (24.7)

0.153

Diagnosis

0.384

HNP

42 (28.0)

39 (26.0)

Spinal stenosis

66 (44.0)

58 (38.7)

Spondylolisthesis

27 (18.0)

36 (24.0)

Degenerative instability

15 (10.0)

17 (11.3)

4.2 ± 2.1

4.7 ± 2.3

Duration of pain (mo)

P

Ventral ESI

Injection level

0.425 0.538

L3–L4

15 (10.0)

12 (8.0)

L4–L5

86 (57.3)

82 (54.7)

L5–S1

49 (32.7)

56 (37.3)

Oral medication

0.562

None

11 (7.3)

9 (6.0)

NSAIDs

37 (24.7)

42 (28.0)

Paracetamol

65 (43.3)

67 (44.7)

Opioid

37 (24.7)

32 (21.3)

Unless otherwise noted, data are numbers of subjects and percentages within parentheses. ESI indicates epidural steroid injection; BMI, body mass index; HNP, herniated nucleus pulposus; NSAIDs, nonsteroidal anti-inflammatory drugs.

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Ventral Epidural Filling Technique in Interlaminar Epidural Steroid Injection • Jeon et al

TABLE 2. Outcome Parameters of Ventral ESI and Conventional ESI Ventral ESI

Conventional ESI

P

Preinjection

72.2 ± 13.9

74.3 ± 14.1

0.204

Post 1 mo

33.2 ± 15.9

35.8 ± 15.7

0.154

Post 6 mo

40.3 ± 15.2

42.4 ± 15.1

0.242

Post 1 yr

46.4 ± 16.3

47.6 ± 14.7

0.493

Preinjection

55.5 ± 13.4

57.3 ± 15.8

0.286

Post 1 mo

38.5 ± 17.1

37.9 ± 17.8

0.807

Post 6 mo

43.1 ± 15.5

46.1 ± 15.4

0.087

Post 1 yr

48.1 ± 14.2

49.9 ± 15.3

0.262

Preinjection

28.1 ± 11.7

27.9 ± 11.3

0.864

Post 1 mo

15.4 ± 10.3

14.8 ± 12.6

0.670

Post 6 mo

18.1 ± 9.5

16.9 ± 11.7

0.325

Post 1 yr

17.3 ± 10.5

16.7 ± 10.8

0.596

Further ESI within 1 yr

10 (6.7)

14 (9.3)

0.262

Spine surgery within 1 yr

7 (4.7)

5 (3.3)

0.385

9.8 ± 7.3

17.1 ± 11.4

Ventral epidural filling technique in interlaminar epidural steroid injection.

A retrospective case-control study...
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