Multislice CT fluoroscopy-assisted cervical transforaminal injection of steroids: technical note

STUDY DESIGN: A prospective study of 19 consecutive patients who underwent multislice computed tomography (CT)-guided cervical transforaminal steroid injection. OBJECTIVE: To evaluate the feasibility and the outcome of cervical transforaminal steroid injection guided by multislice CT fluoroscopy. SUMMARY OF BACKGROUND DATA: Cervical transforaminal steroid injection has been accepted as an effective therapeutic modality for radiculopathy that results from a cervical herniated disc or stenosis. However, there has been debate on the safety of the transforaminal approach technique, with C-arm fluoroscopy guidance, compared with the posterior interlaminar approach. We present an advanced approach technique for cervical transforaminal steroid injection guided by multislice CT fluoroscopy and the clinical outcomes. METHODS: Nineteen consecutive patients presenting with radiating pain to the shoulder or arm had CT or magnetic resonance image scan findings compatible with cervical herniated disc or foraminal stenosis and were recruited to participate in this study. They underwent cervical transforaminal steroid injection using multislice CT fluoroscopy guidance up to 3 times with a minimal interval of 2 weeks. The participants were evaluated for the safety and efficacy of this technique for a follow-up period of 16 weeks. RESULTS: No serious complications were found during and after the procedures. Eleven patients received a second steroid injection but none required a third injection over the 16-week follow-up period. The mean visual analog scale score improved significantly at 2, 4, 8, and 16 weeks (P < 0.001). CONCLUSIONS: The multislice CT fluoroscopy-guided approach is feasible and a safe and effective approach for cervical transforaminal steroid injection. With the advantages of safety for the patient and precise placement of the needle for injection, this technique might be an additional option and may eventually replace the conventional C-arm fluoroscopy-guided cervical transforaminal steroid injection technique.     

Outcomes of interlaminar and transforminal spinal injections

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.     

Incidence of intravascular penetration in transforaminal cervical epidural steroid injections

STUDY DESIGN A prospective, observational, human, study was conducted. OBJECTIVES To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced transforaminal cervical epidural steroid injections, and to determine whether the observation of blood in the needle hub can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA Incorrectly placed intravascular cervical spinal injections result in medication flow systemically and not to the desired target. A recently published study demonstrates a high incidence of intravascular injections in transforaminal lumbosacral epidural injections. No studies so far have evaluated the incidence of vascular injections in transforaminal cervical epidural steroid injections, nor have they calculated the ability of observed blood in the needle hub to predict a vascular injection in the cervical spine.METHODS The incidence of fluoroscopically confirmed intravascular uptake of contrast was prospectively observed in 337 patients treated with cervical transforaminal epidural steroid injections. The ability of observed blood in the needle hub to predict intravascular injection was also investigated. For each subject, the injection level was chosen on the basis of the clinical scenario including history, physical examination, and review of imaging studies. Some patients had multilevel injections. Using fluoroscopic guidance, the authors placed a 25-gauge needle into the epidural space using a transforaminal approach according to accepted standard technique. Needle tip location was confirmed with biplanar imaging. The presence or absence of blood in the needle hub spontaneously ("flash") and after attempted aspiration by pulling back on the syringe's plunger was documented. Contrast then was injected under real-time fluoroscopy to determine whether the location of the needle tip was intravascular. The results were recorded in a prospective manner indicating the presence or absence of blood in the needle hub and whether a vascular pattern was noted with contrast injection, and these were correlated. Relevant epidemiologic data also were recorded. RESULTS The study included 504 transforaminal epidural steroid injections. The overall rate of fluoroscopically confirmed intravascular contrast injections was 19.4%. Use of observed blood in the needle hub to predict intravascular injections was 97% specific, but only 45.9% sensitive. There was no significant difference in intravascular rates related to age or gender. CONCLUSIONS As compared with a previous study of lumbosacral epidural steroid injections, there is an overall higher incidence of intravascular injections with cervical transforaminal epidural steroid injections. Use of observed blood in the needle hub to predict an intravascular injection is not sensitive, and therefore the absence of blood in the needle hub despite aspiration is not reliable. The reported sensitivity and specificity rates are similar to lumbar data. Fluoroscopically guided procedures without contrast confirmation instill medications intravascularly, and therefore not in the desired epidural location. This study confirms that there is a need not only for fluoroscopic guidance, but also for contrast instillation in cervical transforaminal epidural steroid injections.     

Cerebellar herniation after cervical transforaminal epidural injection

OBJECTIVE: The purpose of this study is to inform readers of potential catastrophic complications associated with performing cervical transforaminal epidural steroid injections. CASE REPORT: A 31-year-old man presented to the pain clinic with a history of cervical radicular pain and right upper-extremity radicular symptoms. He was referred from the orthopedic spine clinic for evaluation for epidural steroid injection, having failed conservative treatment consisting of nonsteroidal anti-inflammatory drugs, muscle relaxants, oral steroids, and physical therapy. After undergoing a transforaminal epidural steroid injection at the right C8 nerve root, he developed a cerebellar infarct and brainstem herniation. He survived but has residual deficits of persistent diplopia on right lateral gaze and difficulties with short-term memory loss and concentration. CONCLUSIONS: Although transforaminal epidural steroid injections are an efficacious treatment for radicular syndromes, there can be catastrophic complications. In light of the growing body of similar case reports, further investigation is warranted to establish a safe protocol for the use of this modality.     

Incidence of intravascular injection and the spread of contrast media during S1 transforaminal epidural steroid injection by two approaches: anteroposterior vs oblique

The aim of this randomised study was to compare the incidence of intravascular injections during S1 transforaminal epidural steroid injection performed in the anteroposterior and oblique views. We also compared epidural spread patterns of contrast media, which included 201 injections at the S1 level. The overall incidence of intravascular injection during S1 transforaminal epidural steroid injection in the anteroposterior view was 29% (29/99), significantly higher than in the oblique view (11%, 11/102, p = 0.001). There were no significant differences between the two groups for epidural spread of contrast media in cases where intravascular injections did not occur (p = 0.77). Performing S1 transforaminal epidural steroid injection in the oblique view rather than the anteroposterior view reduces the risk of intravascular injections.     

Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study

Steroid injections are often employed as an alternative treatment for radicular pain in patients with degenerative spinal disorders. Prospective randomised studies of the lumbar spine reveal contradictory results and non-randomised and most often retrospective studies of the cervical spine indicate pain reduction from steroid injections. No prospective randomised study on transforaminal steroid injections for the treatment of radicular pain in the cervical spine focusing on short-term results has been performed. Forty consecutive patients were employed for the study. The inclusion criteria were one-sided cervical radiculopathy with radicular distribution of arm pain distal to the elbow and corresponding significant degenerative pathology of the cervical spine at one or two levels on the same side as the radicular pain and visualised by MRI. A transforaminal technique was used for all injections. A positive response to a diagnostic selective nerve root block at one or two nerve roots was mandatory for all patients. The patients were randomised for treatment with steroids/local anaesthetics or saline/local anaesthetic. Only the neuroradiologist performing the blocks was aware of the content of the injection; all other persons involved in the study were blinded. Follow up was made 3 weeks after the randomised treatment by a clinical investigation and with a questionnaire focusing on the subjective effects from the injections. At follow up, there were no differences in treatment results in the two patient groups. Statistical analysis of the results confirmed the lack of difference in treatment effect. Further studies have to be performed before excluding steroids in such treatment and for evaluating the influence of local anaesthetics on radiculopathy in transforaminal injections.     

Incidence of intravascular penetration in transforaminal lumbosacral epidural steroid injections

STUDY DESIGN: A prospective, observational, human, in vivo study. OBJECTIVES: To evaluate the incidence of vascular penetration during fluoroscopically guided, contrast-enhanced, transforaminal lumbar epidural steroid injections (ESIs) and determine whether a "flash" (blood in the needle hub) or aspiration of blood can be used to predict a vascular injection. SUMMARY OF BACKGROUND DATA: Incorrectly placed, intravascular lumbosacral spinal injections result in systemic medication flow that misses the desired target. No previous studies evaluate the incidence of vascular injections in transforaminal ESIs, nor the ability of flash to predict a vascular injection. METHODS: The incidence of flash or positive blood aspiration and the incidence of fluoroscopically confirmed vascular spread were prospectively observed in 670 patients treated with lumbosacral fluoroscopically guided transforaminal ESIs. Presence of a flash or positive aspiration was documented. Contrast was injected to determine whether the needle tip was intravascular. RESULTS: Seven hundred sixty-one transforaminal ESIs were included. The overall rate of intravascular injections was 11.2%. There was a statistically significant higher rate of intravascular injections (21.3%) noted with transforaminal ESIs performed at S1 (n = 178), compared with those at the lumbar levels (8.1%, n = 583). Using flash or positive blood aspirate to predict intravascular injections was 97.9% specific, but only 44.7% sensitive. CONCLUSIONS: There is a high incidence of intravascular injections in transforaminal ESIs that is significantly increased at S1. Using a flash or blood aspiration to predict an intravascular injection is not sensitive, and therefore a negative flash or aspiration is not reliable. Fluoroscopically guided procedures without contrast confirmation are instilling medications intravascularly and therefore not into the desired epidural location. This finding confirms the need for not only fluoroscopic guidance but also contrast injection instillation in lumbosacral transforaminal ESIs.     

Comparison of posterior and transforaminal approaches to lumbar interbody fusion

STUDY DESIGN: A study of the transforaminal lumbar interbody fusion and the posterior lumbar interbody fusion techniques was performed. OBJECTIVES: To describe the transforaminal lumbar interbody fusion technique, and to compare operative data, including blood loss and operative time, with data from posterior lumbar interbody fusion technique. SUMMARY OF BACKGROUND DATA: The evolution of posterior lumbar fusion combined with anterior interbody fusion has resulted in increased fusion rates as well as improved reductions and stability. The transforaminal lumbar interbody fusion technique pioneered by Harms and Jeszensky offers potential advantages and provides a surgical alternative to more traditional methods. METHODS: In 13 consecutive months, two spinal surgeons performed 40 transforaminal lumbar interbody fusions and 34 posterior lumbar interbody fusion procedures. Data regarding blood loss, operative times, and length of hospital stay were recorded. These data were analyzed using analysis of variance to show any significant differences between the two techniques. To determine whether differences in measured variables were dependent on patient gender or number of levels fused, epsilon(chi2) analysis was used. RESULTS: No significant differences were found between transforaminal and posterior lumbar interbody fusions in terms of blood loss, operative time, or duration of hospital stay when a single-level fusion was performed. Significantly less blood loss occurred when a two-level fusion was performed using the transforaminal approach instead of the posterior approach (P < 0.01). Differences in measured variables for the two procedures were independent of patient age, gender, and the number of levels fused. There were no complications with the transforaminal approach, but the posterior approach resulted in multiple complications. CONCLUSIONS: In this comparison of patients receiving transforaminal lumbar interbody fusion versus posterior lumbar interbody fusion, no complications occurred with the transforaminal approach, whereas multiple complications were associated with the posterior approach. Similar operative times, blood loss, and duration of hospital stay were obtained in single-level fusions, but significantly less blood loss occurred with the transforaminal lumbar interbody approach in two-level fusions. The transforaminal procedure preserves the interspinous ligaments of the lumbar spine and preserves the contralateral laminar surface as an additional surface for bone graft. It may be performed at all lumbar levels because it avoids significant retraction of the dura and conus medullaris.     

经椎间孔入路腰椎体间融合术治疗腰椎不稳症

目的探讨经腰椎间孔入路行腰椎椎体间植骨融合术治疗腰椎不稳症的手术适应证、技术要点及应用价值。方法自2002年2月~2005年3月,对腰椎不稳56例行腰椎后正中入路,经单侧腰椎间孔行椎体间植骨融合,腰椎后方上下椎板间、棘突间、关节突间植骨,以及相应节段椎弓根钉内固定术。结果56例手术切口均一期愈合,无神经损伤、椎间隙感染和脑脊液漏等并发症。52例经6~37个月随访,平均16个月,未发生内置物断裂、松动移位和椎间隙高度丧失,骨融合率为90·38%。依据日本JOA疗效评定标准,优29例,良16例,可3例,差4例,总优良率为86·5%。结论经腰椎间孔入路椎间植骨融合术(TLIF)治疗腰椎不稳症,不但技术操作可行,而且能明显降低因侵入椎管而带来的各种可能发生的并发症,是治疗退变性腰椎不稳症的有效手术方式。     

Reversible posterior leukoencephalopathy syndrome after cervical transforaminal epidural steroid injection presenting as transient blindness

Transforaminal epidural steroid injections have been introduced as a nonsurgical treatment for cervical pain syndromes; however, they have also raised safety concerns. We present a patient who developed a headache and bilateral visual disturbance after cervical transforaminal epidural steroid injections. Brain magnetic resonance imaging showed a high signal intensity in the posterior region on T2-weighted and fluid-attenuated inversion recovery images, and the findings of diffusion-weighted imaging and the apparent diffusion coefficient map suggested vasogenic edema. The symptoms and abnormal imaging findings disappeared during follow-up. The clinical and imaging characteristics and their complete reversibility corresponded to reversible posterior leukoencephalopathy syndrome.     

Infarction of the Cervical Spinal Cord Following Multilevel Transforaminal Epidural Steroid Injection: Case Report and Review of the Literature

Abstract

Background/Objective: Transforaminal epidural steroid injection is a widely utilized nonsurgical strategy for the management of cervical radicular and axial pain. The technique has been shown to be efficacious in relieving the patients' symptoms. Although effective, there are a range of possible complications associated with this procedure. We report the case of a patient with an acute infarction of the cervical spinal cord after a multilevel transforaminal epidural steroid injection.

Methods: We performed a retrospective chart review of a single case.

Results: The patient suffered an acute brainstem and cervical spinal cord infarction despite the use of many techniques to minimize the occurrence of vascular injury during the procedure. The patient regained some function after medical and physical therapy.

Conclusions: This complication, to our knowledge, has only been reported in the literature on 2 other occasions and serves as a reminder of the potentially devastating consequences of performing procedures in proximity to the nervous system.     

Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study

Summary Background. The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk of complications. Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes radicular pain, and therefore steroids placed locally should relieve symptoms. Methods. During a 12-month period, 21 secondary referral patients with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval, while waiting for operative treatment. The pain intensity (VAS), Odom’s criteria and operative indications were registered at 6 weeks and 4 months. Findings. After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as positively as those with disc herniation. Interpetation. This prospective cohort study indicates a reduction in the need for operative treatment due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.     

Cervical transforaminal injection and the radicular artery: variation in anatomical location within the cervical intervertebral foramina

BACKGROUND: Recent articles have detailed the adverse events associated with transforaminal steroid injections into the radicular arteries. Guidelines on strict transforaminal epidural techniques have been described to limit complications. There remains limited information regarding the cervical level of entry, location within the intervertebral foramina, and prevalence of the radicular arteries within the population. METHODS: With the aid of premortem angiography and postmortem latex-injected vasculature, a single detailed cadaveric dissection was performed to elucidate the specific anatomic location of the radicular arteries within the intervertebral foramina and the anastomoses of the arteries to the anterior spinal artery. RESULTS: Five radicular arteries (C5, C6, two at C7, C8) were traced entering the foramina either anteriorly or posteriorly to supply the anterior and posterior spinal arteries. Radicular arteries received blood supply from either the deep cervical (C8) or vertebral arteries. The C8 radicular artery entered the lateral aspect of the foramen and penetrated the dural sleeve within the inferior portion of the foramen, directly inferior to the exiting spinal nerve, to supply the anterior spinal artery. This artery was of a large enough caliber to be entered by a 22-gauge needle. CONCLUSIONS: A larger population is necessary to characterize the range of anatomic variations in arterial supply within the foramina. Available studies support the current technique of fluoroscopic needle insertion. Yet, there is wide anatomic variation in the origin and location of these vessels, and even with strict adherence to technique, it is feasible that a properly placed needle could penetrate a radicular artery.     

Incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections.

BACKGROUND CONTEXT: The incidence of vascular penetration during contrast confirmed fluoroscopically guided transforaminal lumbosacral epidural injections has been reported as 8.9% to 21.3% depending on the level of injection. Recently, intermittent fluoroscopy was shown to miss more than half of the vascular injections observed under live fluoroscopy. The number of misses increased when epidural and vascular contrast flow appeared simultaneously, even if the fluoroscopic image was taken during contrast injection. To date, no studies have documented the incidence of simultaneous epidural and vascular contrast injections. Also, most previous studies of vascular injections did not document use of live fluoroscopy during contrast injection, so the incidence of vascular injections may be higher than reported. PURPOSE: To determine the incidence of simultaneous epidural and vascular contrast injection during lumbosacral transforaminal epidural injections. STUDY DESIGN/SETTING: A prospective, observational, in vivo, study. PATIENT SAMPLE: Patients receiving lumbar transforaminal epidural injections at a university-based outpatient spine center. OUTCOME MEASURES: Incidence of epidural, vascular, and simultaneous epidural and vascular contrast patterns. METHODS: One interventional spine physician and three fellows under his direct supervision recorded contrast patterns observed during 191 fluoroscopically guided lumbosacral transforaminal epidural steroid injections with injection of contrast observed under live fluoroscopy. RESULTS: The incidence of simultaneous epidural and vascular injection during lumbosacral transforaminal epidural injections was 8.9%. The incidence of a vascular injection alone was 4.2%, for a total vascular injection incidence of 13.1%. Subjects with a simultaneous epidural and vascular injection who returned for repeat injection had a statistically significant chance of a repeat simultaneous epidural and vascular injection when the injection was done at the same location. Fluoroscopy time was significantly increased, an average of 8.8 seconds, when a vascular injection was identified. There was no statistically significant correlation between the incidence of simultaneous epidural and vascular injection with subjects' age, sex, level of injection, side of injection, needle gauge, or diagnosis. CONCLUSIONS: Simultaneous epidural and vascular injection is twice as likely to occur as vascular injection alone. Use of intermittent fluoroscopy can miss the transient appearance of the vascular component of these injections, giving the false impression of successful contrast placement. In light of these results, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.     

Transforaminal Thoracic Interbody Fusion (TTIF) for Treatment of a Chronic Chance Injury

Multiple anterior and posterior approaches to the thoracic disc space have been reported. However, we are not aware of any previous reports describing a transforaminal approach for thoracic disc release and interbody cage placement. In this case report, we describe a method to perform transforaminal thoracic interbody fusion (TTIF), which is an adaptation of an established lumbar fusion technique (transforaminal lumbar interbody fusion). Key differences between the two procedures are discussed. A 24-year-old woman presented after sustaining a T11-12 Chance fracture that had been treated in a brace. She had severe, debilitating pain and a rigid segmental kyphotic deformity of 38°. The patient was treated 3 months post-injury with T10-L1 fusion with anterior release and interbody fusion with cage placement at T11-12. Anterior column release and fusion were performed via a transforaminal approach. The patient had anatomic reduction of deformity, solid arthrodesis, and relief of pain at 1-year follow-up. The TTIF approach permits access to the anterior column of the thoracic spine for the purpose of reduction of deformity and interbody fusion with reduced morbidity compared to anterior–posterior surgery.     

椎间孔镜微创治疗腰椎间盘突出症近期疗效观察

目的：应用经皮椎间孔镜技术微创治疗腰椎间盘突出症,观察其临床治疗效果。方法;应用经皮椎间孔镜治疗腰椎间盘突出症患者28例,康复策略采用早期功能锻炼与腰椎稳定的原则进行,手术效果按照视疼痛模拟评分（VAS）和改良MacNab标准进行评定。结果：所有患者均成功实施手术,术后随访时间3个月,腰腿痛VAS评分较术前明显改善;根据改良MacNab标准优良率89.3％。结论：经皮椎间孔镜技术是治疗腰椎间盘突出症安全、有效的微创治疗办法：采用有效的康复手段,可以最大限度的减少复发,取得最大的治疗效果。     

Unilateral transforaminal posterior lumbar interbody fusion.

A prospective analysis of consecutive patients who had lumbar fusion using the unilateral transforaminal posterior lumbar interbody fusion with pedicle screw fixation is presented to assess the clinical and radiographic outcomes of the transforaminal posterior lumbar interbody fusion procedure and describe the technique and indication in the treatment of degenerative disease of the lumbar spine. Forty patients treated with transforaminal posterior lumbar interbody fusion for degenerative diseases of the lumbar spine (with anterior column deficiency) were followed up for a minimum of 3 years (mean, 3.4 years; range, 3-3.9 years). Radiographic assessment included plain and flexion and extension radiographs. Clinical outcome was based on pain relief, ability to do activities of daily living, and return to work. Thirty-six patients (90%) had solid fusions and at latest followup, segmental lordosis has increased in all patients. Eighty-five percent of patients had excellent or good clinical outcome(s). The unilateral transforaminal posterior lumbar interbody fusion provides bilateral anterior column support through a unilateral approach. The patients had high fusion rates and patient satisfaction as reported with similar complications found in other methods commonly used for spinal decompression and stabilization.     

CT引导下神经根脉冲射频联合局部注射复方倍他米松治疗腰椎间盘突出症

目的探讨cT引导下神经根脉冲射频加神经根周围注射倍他米松治疗腰椎间盘突出症的疗效。方法2012年5月～2013年2月,对46例腰椎间盘突出症,在cT导引下精确定位神经根后,突出椎间盘节段神经根脉冲射频治疗,相应椎间孔内神经根周围注射倍他米松1ml＋生理盐水1ml。结果均顺利完成治疗,无并发症。术后6个月随访,按改良MaeNab标准：优28例,良12例,可4例,差2例,优良率87．O％（40／46）,有效率95．7％（44／46）。结论神经根脉冲射频加神经根周围药物注射是腰椎间盘突出症的一种微创、有效、安全的治疗方法。     

A New full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients.

Even with good results, conventional disc operations may result in consecutive damage due to traumatisation. Endoscopic techniques have become the standard in many areas because of the advantages they offer in surgical technique and in rehabilitation. The transforaminal operation is the most common full-endoscopic procedure in surgery of the lumbar spine. It is frequently necessary to reach the spinal canal directly in order to achieve sufficient resection of lumbar disc herniations. Even in using a lateral approach, the authors recognise the clear limitations of the transforaminal procedure. The objective of this prospective study was to examine the technical possibility of a full-endoscopic interlaminar access. The focus was on questions of sufficient decompression, as well as advantages and disadvantages of the minimally invasive procedure. 331 patients were followed for 2 years. The results show that 82 % reported no longer having leg pain, and 13 % had only occasional pain. The decompression results are equivalent to those of conventional procedures. Traumatisation of both the access pathway and the spinal canal structures was reduced. Epidural scarring was minimised. The recurrence rate was 2.4 %. No serious surgical complications were observed. The authors view the technique described, which offers the advantage of a truly minimally invasive procedure, as a sufficient and safe alternative to conventional procedures, when the appropriate indication criteria are heeded. There are technical problems because of the small instruments. In conjunction with the transforaminal procedure, this is an expansion of the spectrum for full-endoscopic surgery of lumbar disc herniations.     

Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection:A case report and review of the literature

A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection(ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel(antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors' knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking antiplatelet medications.