Epidural injections for the treatment of symptomatic lumbar herniated discs

Epidural steroid injections are widely used as part of the conservative care for symptomatic herniated lumbar discs. There are studies showing their effectiveness, and some studies demonstrating no clinical benefits. The purpose of this study was to evaluate the effectiveness of epidural steroid injections for patients with symptomatic lumbar disc herniations who were surgical candidates. Sixty-nine patients were diagnosed with a herniated disc in the lumbar spine and remained symptomatic despite conservative care, and were treated with an epidural injection in an attempt to avoid surgical discectomy. Of the total group of 69 patients (average age = 44.8 years, range 19-77 years, average follow-up = 1.5 years), 53 (77%) had successful resolution or significant decrease of their symptoms and were able to avoid surgery. Only 16 (23%) patients failed to have significant relief of their symptoms and required surgical treatment of their herniated disc. Epidural steroid injections have a reasonable success rate for the alleviation of radicular symptoms from lumbar herniated discs for up to twelve to twenty-seven months. Patients treated with injections may be able to avoid surgical treatment up to this period and perhaps even longer.     

Concomitant sacroiliac joint pain in patients with lumbar disc herniation: case series

Recent studies have shown that not all lumbar disc herniations are symptomatic and that when followed longitudinally, these patients develop back pain independent of the previous imaging study. This is a case report of two patients with radicular symptoms and lumbar disc herniations that underwent diagnostic injections to locate their pain generator. Both patients failed to respond to transforaminal epidural steroid injections. Transforaminal injections can be diagnostically sensitive for radicular pain but not specific. This is a direct result of the spread of medication to other levels in the epidural space, thus affecting multiple levels of innervation. Follow-up with two sacroiliac injections gave significant relief of their pain. They were both treated conservatively for sacroiliac joint pain and did well. One remained pain free after several months and the second remained with minimal pain until she presented again in her 3rd month of pregnancy with return of her pain. The differential diagnosis of lumbar radicular pain is discussed as well as the authors' experience in using diagnostic injections.     

Lumbar disc herniation regression after successful epidural steroid injection

In some lumbar disc herniation patients, noninvasive measures fail, necessitating more aggressive treatment, such as epidural steroid injections or surgery. This study sought to determine whether improvement in patients who receive epidural steroid injections is related to regression of herniated nucleus pulposus or whether such patients' symptoms decrease because of the steroid effect in the presence of continued herniated nucleus pulposus. Two nonoperatively treated patient cohorts were followed who had follow-up MRI. Specifically, 38 other patients who improved without invasive treatment within 6 weeks after the onset of their symptoms were compared with 20 patients who improved with epidural steroid injections. Results found that both groups had similar initial and follow-up herniated nucleus pulposus size and outcomes. The epidural steroid injection group had fewer sequestered or extruded herniations that resorbed, and most were of lower hydration. In conclusion, epidural steroid injections do not alter ultimate herniated nucleus pulposus regression. Patients in whom the disc herniation has less hydration may have prolonged symptoms, but many improve with epidural steroid injections.     

A retrospective analysis of the efficacy of epidural steroid injections

Forty patients were studied retrospectively to evaluate the effect of epidural steroid injections on low back pain and sciatica characteristic of spinal stenosis or a herniated lumbar disc. All but one of these patients had radicular symptoms. The average age was 55 years, and the average follow-up time was eight months. All patients were injected by the same anesthesiologist with 2 cc of Depomedrol-40. Thirty-six patients received either one, two, or three injections. Four patients received either four or five injections. The overall results were poor, with about 60% of patients reporting varying degrees of relief from leg and back pain immediately after injection. However, at follow-up examination, only 24% were asymptomatic; 40% reported no change in preinjection numbness, weakness, or pain; and approximately 35% had varying degrees of relief with no consistent pattern. Of those who had complete relief, there was no correlation between relief of pain, age, or number of injections. From this study, it appears that approximately 50% of patients with radicular symptoms may receive temporary relief with steroid injection. However, long-term relief occurs in less than 25% of patients.     

Effect of the transligamentous extension of lumbar disc herniations on their regression and the clinical outcome of sciatica

STUDY DESIGN: Magnetic resonance imaging of symptomatic herniated lumbar discs was investigated longitudinally and prospectively for the presence of tear in the posterior longitudinal ligament (PLL). OBJECTIVES: To clarify the effect of transligamentous extension through the PLL of herniated disc on its regression and to determine the factors contributing to a successful clinical outcome. SUMMARY OF BACKGROUND DATA: Greater regression of the herniated fragment has been noted with larger initial disc herniations. The exposure of herniated disc materials to the epidural vascular supply through the ruptured PLL has been suspected to play a part in the mechanism of disappearance of the herniated nucleus pulposus. However, it had not been shown clinically. METHODS: Clinical outcomes and magnetic resonance images of 36 patients with symptomatic lumbar disc herniations, treated conservatively, were analyzed. Patients were divided into three groups: subligamentous, transligamentous, and sequestered herniations. The size of the herniated disc was measured by herniation ratio, which is defined as the ratio of the area of herniated disc to that of the thecal sac on the axial view. Factors associated with the natural regression of herniated disc and the successful clinical outcome were explored. RESULTS: Of the 36 herniated discs, 25 decreased in size. Ten (56%) of 18 subligamentous herniations, 11 (79%) of 14 transligamentous herniations, and all 4 (100%) sequestered herniations were reduced in size. The average decreases in herniation ratio of the subligamentous, transligamentous, and sequestered disc groups were 17%, 48%, and 82% respectively. The decrease in herniation ratio was related to the presence of transligamentous extension but was not related to the initial size of herniation. Successful outcome correlated with a decrease in herniation of more than 20%. CONCLUSION: Transligamentous extension of herniated disc materials through the ruptured PLL is more important to its reduction in size than is the initial size of the herniated disc. Decrease in herniation ratio of more than 20% seems to correspond to successful clinical outcome.     

Intradural disc herniations in the cervical, thoracic, and lumbar spine: report of three cases and review of the literature

The clinical, neuroradiological, and surgical management of three cases of intradural disc herniations--one each in the cervical, thoracic, and lumbar regions--are presented. Intradural disc herniations comprise only 0.27% of all herniated discs. Three percent occur in the cervical, 5% in the thoracic, and 92% in the lumbar spinal canal. Those with cervical or thoracic lesions frequently exhibit profound myelopathy, whereas those with lumbar lesions demonstrate radicular or cauda equina syndromes. Although varying combinations of the MRI, non-contrast CT, myelogram, and myelo-CT scans may at times fail to accurately establish the diagnosis of an intradural disc herniation prior to surgery, the index of suspicion raised by the lack of clinical correlation with surgical findings justifies an intradural exploration.     

The value of spinal computed tomography in diagnosis of herniated lumbar discs

Summary In this study the diagnostic value and topographical accuracy of spinal computed tomography (CT) in the preoperative diagnosis of lumbar disc herniations were tested in 36 patients with surgically proven herniated discs. All patients also underwent metrizamide myelography. CT findings and myelograms were compared and correlated with the surgical observations. Especially in demonstrating exact diagnosis (lateral or more medial protrusion), and in showing the extent of upward or downward displacement of free disc material, CT provides valuable preoperative information. As a non-invasive diagnostic procedure, spinal CT scan may replace lumbar myelography in many patients with radicular lumbar pain.     

Symptomatic gas-containing disc herniation. Report of four cases

Intradiscal gas collection, causing the radiographic vacuum phenomenon, is a common finding on radiographic studies of the lumbar spine. Four cases of radiographically documented and surgically confirmed cases of herniated discs containing gas are presented. All four patients presented with radicular symptoms secondary to the gas-containing herniations. Minimal nuclear material was found at surgery; however, all patients experienced relief after the operation.     

Lumbar epidural gas-containing pseudocysts as a cause of severe radicular pain

Objectives

Intradiscal gas can herniate to the epidural space, and herniated epidural gas may produce pseudocysts. We assessed the characteristics of and surgical treatments for lumbar epidural gas-containing pseudocysts as a cause of severe radicular pain.

Methods

We surgically treated epidural gas-containing pseudocysts in a total of 22 patients. We reviewed radiological parameters including the concomitant presence of vacuum discs, segmental instability, spinal stenosis, and location of pseudocysts. We retrospectively reviewed preoperative clinical parameters such as age, sex, clinical symptoms, neurologic deficits, and surgical methods.

Results

We observed 25 levels of gas-containing pseudocysts in 22 patients. Twelve (48.0%) pseudocysts were in the canal, eight (32.0%) were in the foramen, and five (20.0%) were of extraforaminal type. All of the patients had degenerative vacuum discs in the affected levels. The incidence of neurologic deficits in patients with spinal stenosis was significantly higher than in patients without spinal stenosis (P < 0.05).We performed pseudocyst removal, neural decompression, and fusion surgery in 12 patients with symptomatic spinal stenosis or instability, and microscopic removal of pseudocysts in 10 patients without symptomatic spinal stenosis or instability.

Conclusion

We propose that lumbar gas-containing pseudocysts can produce radicular pain and/or neurologic symptoms, and that surgical removal of pseudocysts with or without optimal stabilization operations can significantly improve symptoms. The selection of surgical methods may depend on the presence of concomitant spinal stenosis or segmental instability.     

Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study

BACKGROUND: Epidural steroid injection is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation. The objective of this study was to determine the efficacy of epidural steroid injection in the treatment of patients with a large, symptomatic lumbar herniated nucleus pulposus who are surgical candidates. METHODS: One hundred and sixty-nine patients with a large herniation of the lumbar nucleus pulposus (a herniation of >25% of the cross-sectional area of the spinal canal) were followed over a three-year period. One hundred patients who had no improvement after a minimum of six weeks of noninvasive treatment were enrolled in a prospective, non-blinded study and were randomly assigned to receive either epidural steroid injection or discectomy. Evaluation was performed with the use of outcomes scales and neurological examination. RESULTS: Patients who had undergone discectomy had the most rapid decrease in symptoms, with 92% to 98% of the patients reporting that the treatment had been successful over the various follow-up periods. Only 42% to 56% of the fifty patients who had undergone the epidural steroid injection reported that the treatment had been effective. Those who did not obtain relief from the injection had a subsequent discectomy, and their outcomes did not appear to have been adversely affected by the delay in surgery resulting from the trial of epidural steroid injection. CONCLUSIONS: Epidural steroid injection was not as effective as discectomy with regard to reducing symptoms and disability associated with a large herniation of the lumbar disc. However, epidural steroid injection did have a role: it was found to be effective for up to three years by nearly one-half of the patients who had not had improvement with six or more weeks of noninvasive care.     

Far-lateral disc herniations: the results of conservative management

The far-lateral herniated lumbar disc has become increasingly recognized as a cause for low back pain and lumbar radiculopathy as well as for "failed back syndrome" in certain improperly diagnosed cases. Several authors have reported that the majority of patients show poor response to conservative measures. To better understand the natural history, we performed a retrospective review of all lumbar herniated discs during a 3-year period, collecting 16 patients with 17 far-lateral disc herniations. All displayed radicular pain in the distribution of the root exiting at the same level as the herniated disc, with or without associated back pain. Twelve of the 17 disc herniations responded to conservative measures and had complete resolution of their radicular pain at follow-up. Also, at long-term follow-up, essentially all patients had experienced satisfactory subjective resolution of their weakness or sensory complaints. Five patients required surgery because of intractable pain despite conservative measures. Although our series for far-lateral disc herniations is small, we found that conservative measures do afford a relatively high nonoperative success rate of approximately 71%. This is in contrast to earlier implied or stated opinions indicating a low rate of successful nonoperative management as low as 10% in one series.     

A minimally invasive transmuscular approach to far-lateral L5-S1 level disc herniations: a prospective study

BACKGROUND: Among all lumbar disc herniations, L5-S1 far-lateral disc herniations are rare entities. Besides, surgical approach may be difficult because of the very narrow passage at this level. For these 2 reasons, most spine surgeons are not experienced in herniations at this level. According to new microanatomic studies, previous lateral approaches at this level often do not allow access to the neuroforamen without partial or total destruction of the L5-S1 facet joint. To preserve the facet joint, an approach was developed. PURPOSE: To assess the efficacy of a surgical technique that is a minimally invasive intermuscular approach (MIIMA) for decompression of L5-S1 far-lateral level disc herniation (FLLDH). STUDY DESIGN: We present a prospective clinical study analysis of 14 patients with L5-S1 far-lateral disc herniations in a period between 2000 and 2004, treated with microsurgical technique. METHODS: An imaging study revealed consistency with the patient's clinical presentation. In our department, a total of 580 patients underwent discectomy between 2000 and 2004 for lumbar disc herniation. RESULT: Twenty-eight patients had foraminal or extraforaminal herniations (4.8%). Fourteen patients had FLLDH at the L4-L5 level (2.4%), whereas the other 14 were cases of FLLDH at the L5-S1 level (2.4%). One patient had FLLDH at both L5-S1 and L4-L5 levels (7.1%). The mean age of patients was 53.6 years, and the male:female ratio was approximately 5:9. All patients failed to recover after at least 6 weeks of conservative therapy. The mean duration of symptoms until the time of surgery was 7.2 months. Using this MIIMA technique, the authors removed the herniated discs compressing the (L5) nerve roots. Clinical outcome was measured using the visual analog scale. Every patient was discharged within 24 hours. Satisfactory (excellent or good) results were demonstrated in 13 patients (92.9%), because, except for 1 (7.1) permanent dysesthesia case, 4 cases (21.3%) were temporary dysesthesia. Postoperatively all patients reported excellent relief of their sciatic pains, and there were no technique-associated complications. No recurrence was observed during the follow-up period ranging from 10 to 60 months (mean, 29 mo). This is one of the major complications of any approach to a far-lateral disc. CONCLUSIONS: The authors describe a MIIMA for excising herniated discs that is applicable to all types of far-lateral lumbar herniations. Postoperative dysesthesia is the most important complication and may persist as it did in our cases. Consequently, manipulation of the ganglion should be avoided at all costs, if possible. The MIIMA procedure provides a simple alternative for treating lumbar foraminal or lateral exit zone herniated discs in selected cases. This approach is effective, allowing the preservation of the L5-S1 facet joint, saving the facet joint, preventing postoperative instability, and offering a direct view of the L5-S1 neuroforamen.     

极外侧腰椎间盘突出症的临床分型及手术方式选择

目的 提出极外侧腰椎间盘突出症的新的临床分型,为手术方式的选择提供依据.方法 按照椎间盘突出的位置及其临床症状将极外侧腰椎间盘突出症分为椎管内椎间孔内型(Ⅰ型)、椎间孔内型(Ⅱ型)和椎间孔外型(Ⅲ型).据此对2002年1月至2007年1月收治的38例极外侧椎间盘突出症患者进行临床分型,并结合临床分型选择(1)经横突间椎间盘切除;(2)经椎管部分关节突切除、潜行椎间盘切除;(3)经椎管椎间盘切除+经后路椎体间融合(PLIF)等手术方式.38例患者中男性25例,女性13例;平均58.4岁.其中L_(3～4) 17例、L_ (4～5) 13例、L_5S_1 8例.单纯椎间盘突出23例,合并椎管狭窄15例.所有病例均表现为突出节段出口根受压的症状和体征,其中Ⅰ型中的7例同时伴有下位神经根受压的表现,15例合并椎管狭窄者存在间歇性跛行,21例有明确的腰痛症状.手术前后行根性疼痛VAS评分,术后采用MacNab方法进行临床疗效评定.结果 按照新的临床分型,38例患者中Ⅰ型10例、Ⅱ型19例、Ⅲ型9例.经横突间行椎间盘切除5例,经椎管部分关节突切除、潜行椎间盘切除7例,经椎管椎间盘切除+PLIF 26例.随访时间6个月～4年10个月,平均2年11个月.VAS评分术前平均为7.4分,术后2周为2.7分,末次随访为3.1分.末次随访MacNab评定结果:优20例、良12例、可5例、差1例,优良率为84.2%.并发症:伤口表浅感染1例、减压不满意者1例、脑脊液漏1例.未见内固定断裂、松动等.结论 新的临床分型,对认识极外侧腰椎间盘突出症的病理变化及选择手术方式等具有重要的意义.     

Resorption of thoracic disc herniation. Report of 2 cases

The authors describe 2 cases of thoracic disc herniation, resulting in acute myelopathy without bladder dysfunction or progressive muscular weakness; the herniated disc apparently resorbed without surgical intervention. Thoracic disc herniations are less frequent than cervical or lumbar disc herniations and are usually associated with severe neurological deficits. In these 2 cases, the herniated discs exhibited marked decreases in size, corresponding to a favorable clinical outcome within a few months after the initiation of conservative treatment with prostaglandin E(1) and/or steroids in conjunction with physical therapy. The authors conclude that thoracic herniated discs are capable of undergoing natural resorption and that conservative treatment could be indicated, even in the presence of moderate myelopathy, when the myelopathy is not accompanied by bladder dysfunction or progressive muscular weakness.     

极外侧型腰椎间盘突出症的特征及分型 --附36例报告

目的：探讨极外侧型腰椎间盘突出症的特征及分型。方法：对36例极外侧型腰椎间盘突出症患者的临床症状、体征及影像学结果逐项进行分析。结果：发现极外侧型腰椎间盘突出症具有症状重、体征明显、多损伤同位神经根，一半以上损害两神经根以及保守治疗效果差等特征。根据影像学突出物的位置作者将其分为3型：即神经根管型、外口型和混合型。根据不同的类型，采取不同的手术方式，取得了良好的效果。结论：极外侧型腰椎间盘突出症症状重，保守治疗基本无效，应尽早进行手术治疗。     

磷脂酶A_2活性异常升高可能是腰椎间盘突出症疼痛重要病因

目的 :探讨腰椎间盘突出症疼痛的可能病因。方法 :用微量酸滴定法测定椎间盘、黄韧带和硬膜外脂肪中 PL A2 活性。结果 :腰椎间盘突出症患者椎间盘、黄韧带和硬膜外脂肪中 PL A2 活性升高均有显著性意义 (三者 P均 <0 .0 0 1)且三者间均有相关性 (r椎 ,黄 =0 .6 86 3,P=0 .0 0 1;r=椎 ,硬 =0 .7388,P<0 .0 0 1;r黄 ,硬 =0 .6 113,P<0 .0 0 5 )。结论 :椎间盘退变的病理变化不仅发生在椎间盘本身 ,还涉及到同一节段的黄韧带和硬膜外脂肪 ,可能是它们中活性异常升高的 PL A2 共同作用神经根而致痛的。     

Anterior or posterior approach of thoracic disc herniation? A comparative cohort of mini-transthoracic versus transpedicular discectomies

Background contextThe optimal surgical treatment of thoracic disc herniations remains controversial and depends on the consistency of the herniation and its location related to the spinal cord.PurposeTo compare the outcomes of patients with symptomatic thoracic disc herniations treated with anterolateral mini-transthoracic approach (TTA) versus posterior transpedicular discectomy.Study designThis is a prospective comparative cohort study.Patient sampleOne hundred consecutive patients with symptomatic thoracic herniated discs were operated by mini-TTA (56 patients) or transpedicular discectomy (44 patients).Outcome measuresNeurologic assessment by American Spinal Injury Association (ASIA) Impairment Scale and patients' self reported perceived recovery and complications.MethodsThe consistency and location of the herniated disc in relation to the spinal cord was evaluated by preoperative computed tomography and magnetic resonance imaging. Patients were assessed neurologically before surgery and at regular outpatient controls at 2 months or later. Long-term follow-up was achieved by questionnaires sent by mail.ResultsIn both groups, most patients had symptoms of myelopathy and radicular pain; patients who underwent mini-TTA, more frequently suffered from spasticity. Fifty-eight percent of the herniated discs were calcified and 77% were larger than one-third of the spinal canal. All patients presented with ASIA Grade C or D (64%) or ASIA Grade E (36%). Postoperatively, 50% of the patients treated with mini-TTA and 37% of the transpedicular group improved at least one grade on the ASIA scale (p=.19). The duration of surgery, blood loss, hospital stay, and complication rate were significantly higher in patients treated with mini-TTA and were mainly related to the magnitude and consistency of the herniated disc. At long-term follow-up, 72% of the mini-TTA patients reported good outcome versus 76% of the transpedicular discectomy group (p=.80).ConclusionsSurgical treatment of a symptomatic herniated disc contributed to a clinical improvement in most cases. The approach is dependent on the location, the magnitude, and the consistency of the herniated thoracic disc. Medially located large calcified discs should be operated through an anterolateral approach, whereas noncalcified or lateral herniated discs can be treated from a posterior approach as well. For optimal treatment of this rare entity, the treatment should be performed in selected centers.     

Treatment of lumbosacral radicular pain with epidural steroid injections

Fifty patients with an average age of 47 years received epidural steroid injections for lumbosacral radicular pain due to disk herniation or spinal stenosis. All patients had failed previous conservative treatment. Mean follow-up was 24 months (range: 12-36 months). Immediately after injection, all 50 patients reported various degrees of relief from leg and back pain. At the last follow-up examination, 68% of patients were asymptomatic, 20% had no change in preinjection radicular symptoms, and 12% had various degrees of relief. No significant correlation was found between pain relief, age, or number of injections. Early pain relief may be anticipated after epidural steroid injections in 80% of patients with radicular symptoms due to disk herniation or spinal stenosis.     

颈椎间盘突出症磁共振成像特点及临床意义

本文报告颈椎间盘突出症80例,术前经MRI检查,突出椎间盘共154个,其中突出椎间盘明显压迫硬膜囊126个.根据MRI影像学改变,结合临床表现及X线颈椎常规片综合分析,施行颈前路突出椎间盘髓核摘除减压64例(91个椎间盘),优良46例(71.87%),好转14例(21.88%).认为MRI矢状切面可显示突出及脱出影像特点,并可直观脊髓受压节段,根据脊髓信号强弱判断其受损程度.横切面可观察到椎间盘突出类型及神经根脊髓受累情况.     

Combined intra-extracanal approach to lumbosacral disc herniations with bi-radicular involvement. Technical considerations from a surgical series of 15 cases

Large lumbosacral disc herniations effacing both the paramedian and the foraminal area often cause double radicular compression. Surgical management of these lesions may be difficult. A traditional interlaminar approach usually brings into view only the paramedian portion of the intervertebral disc, unless the lateral bone removal is considerably increased. Conversely, the numerous far-lateral approaches proposed for removing foraminal or extraforaminal disc herniations would decompress the exiting nerve root only. Overall, these approaches share the drawback of controlling the neuroforamen on one side alone. A combined intra-extraforaminal exposure is a useful yet rarely reported approach. Over a 3-year period, 15 patients with bi-radicular symptoms due to large disc herniations of the lumbar spine underwent surgery through a combined intra-extracanal approach. A standard medial exposure with an almost complete hemilaminectomy of the upper vertebra was combined with an extraforaminal exposure, achieved by minimal drilling of the inferior facet joint, the lateral border of the pars interarticularis and the inferior margin of the superior transverse process. The herniated discs were removed using key maneuvers made feasible by working simultaneously on both operative windows. In all cases the disc herniation could be completely removed, thus decompressing both nerve roots. Radicular pain was fully relieved without procedure-related morbidity. The intra-extraforaminal exposure was particularly useful in identifying the extraforaminal nerve root early. Early identification was especially advantageous when periradicular scar tissue hid the nerve root from view, as it did in patients who had undergone previous surgery at the same site or had long-standing radicular symptoms. Controlling the foramen on both sides also reduced the risk of leaving residual disc fragments. A curved probe was used to push the disc material outside the foramen. In conclusion, specific surgical maneuvers made feasible by a simultaneous extraspinal and intraspinal exposure allow quick, safe and complete removal of lumbosacral disc herniations with paramedian and foraminal extension.