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The Use of Magnetic Resonance Imaging to Predict the Clinical Outcome of Non-Surgical Treatment for Lumbar Interverterbal Disc Herniation

Choi SJ, Song JS, Kim C, Shin MJ, Ryu DS, Ahn JH, Jung SM, Park MS - Korean J Radiol (2007 Mar-Apr)

Bottom Line: A successful outcome required a patient satisfaction score greater than two and a pain reduction score greater than 50%.There was no significant difference between the responders and non-responders in terms of the type, hydration and size of the HIVD, or an association with spinal stenosis (p > 0.05).MRI could play an important role in predicting the clinical outcome of non-surgical transforaminal ESI treatment for patients with lumbar HIVD.

Affiliation: Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung, Korea.

ABSTRACT

Objective: We wanted to investigate the relationship between the magnetic resonance (MR) findings and the clinical outcome after treatment with non-surgical transforaminal epidural steroid injections (ESI) for lumbar herniated intervertebral disc (HIVD) patients.

Materials and methods: Transforaminal ESI were performed in 91 patients (50 males and 41 females, age range: 13-78 yrs) because of lumbosacral HIVD from March 2001 to August 2002. Sixty eight patients whose MRIs and clinical follow-ups were available were included in this study. The medical charts were retrospectively reviewed and the patients were divided into two groups; the successful (responders, n = 41) and unsatisfactory (non-responders, n = 27) outcome groups. A successful outcome required a patient satisfaction score greater than two and a pain reduction score greater than 50%. The MR findings were retrospectively analyzed and compared between the two groups with regard to the type (protrusion, extrusion or sequestration), hydration (the T2 signal intensity), location (central, right/left central, subarticular, foraminal or extraforaminal), and size (volume) of the HIVD, the grade of nerve root compression (grade 1 abutment, 2 displacement and 3 entrapment), and an association with spinal stenosis.

Results: There was no significant difference between the responders and non-responders in terms of the type, hydration and size of the HIVD, or an association with spinal stenosis (p > 0.05). However, the location of the HIVD and the grade of nerve root compression were different between the two groups (p < 0.05).

Conclusion: MRI could play an important role in predicting the clinical outcome of non-surgical transforaminal ESI treatment for patients with lumbar HIVD.

Transforaminal epidural steroid injection.A. Left anterior oblique radiograph for the right L5 transforaminal injection. The triangle is formed by the iliac crest (IC), the inferior margin of the right transverse process (TP), and the right S1 superior articular process (SAP).B. Left anterior oblique radiograph for needle positioning. The needle tip is inferior and lateral to the right L5 pedicle (p = pedicle).C. Epidurography shows the outline of the right L5 nerve root sleeve (arrows).D. Epidurography for the left L4 transforaminal injection. Contrast is seen outlining the left L4 nerve root sleeve (arrows).E. Epidurography for the right S1 transforaminal injection (arrows).
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Figure 1: Transforaminal epidural steroid injection.A. Left anterior oblique radiograph for the right L5 transforaminal injection. The triangle is formed by the iliac crest (IC), the inferior margin of the right transverse process (TP), and the right S1 superior articular process (SAP).B. Left anterior oblique radiograph for needle positioning. The needle tip is inferior and lateral to the right L5 pedicle (p = pedicle).C. Epidurography shows the outline of the right L5 nerve root sleeve (arrows).D. Epidurography for the left L4 transforaminal injection. Contrast is seen outlining the left L4 nerve root sleeve (arrows).E. Epidurography for the right S1 transforaminal injection (arrows).

Mentions: All procedures were performed in a sterile manner, and fluoroscopic guidance was used for the injections. The patients were placed prone on a fluoroscopy table and the C-arm was rotated to an ipsilateral oblique angle with respect to the suspected nerve root (L4, 5 or S1) (Fig. 1). Lidocaine (1%) was used for the cutaneous and needle tract local anesthesia. After placing a 22 gauge spinal needle at the appropriate level, epidurography with contrast agent was performed to evaluate the anatomy of the epidural space and the distribution of the injection fluid for ensuring that the desired compartment was adequately targeted. We used triamcinolone acetonide suspension 1 cc (TriamcinoloneR 40 mg [Apothecon, Princeton, NJ]) as the long-acting steroid and bupivacain hydrochloride 0.5 cc (MarcaineR 0.5% [Astra USA, Westborough, MA]) as the long-acting local anesthetic. After the procedure, the patient was observed in the short-stay unit for 0.5-1 hour depending on his or her condition. Ten of 68 patients underwent repeat injections; five patients were injected twice, two patients were injected three times, two patients were injected four times and one patient was injected five times. The interval between the injections was three weeks to six months. Although we usually waited 2-3 months before administering repeat injections, the repeat injection was performed in two patients only three weeks after the previous injection. In those patients, we used the half amount of the triamcinolon (20 mg) in the later injections. For the patients who had underwent repeated injections, the requirement of a successful outcome was also a patient satisfaction score greater than two and a pain reduction score greater than 50% at the last visit compared to the score before the injection.

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The Use of Magnetic Resonance Imaging to Predict the Clinical Outcome of Non-Surgical Treatment for Lumbar Interverterbal Disc Herniation

Choi SJ, Song JS, Kim C, Shin MJ, Ryu DS, Ahn JH, Jung SM, Park MS - Korean J Radiol (2007 Mar-Apr)

Transforaminal epidural steroid injection.A. Left anterior oblique radiograph for the right L5 transforaminal injection. The triangle is formed by the iliac crest (IC), the inferior margin of the right transverse process (TP), and the right S1 superior articular process (SAP).B. Left anterior oblique radiograph for needle positioning. The needle tip is inferior and lateral to the right L5 pedicle (p = pedicle).C. Epidurography shows the outline of the right L5 nerve root sleeve (arrows).D. Epidurography for the left L4 transforaminal injection. Contrast is seen outlining the left L4 nerve root sleeve (arrows).E. Epidurography for the right S1 transforaminal injection (arrows).
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Figure 1: Transforaminal epidural steroid injection.A. Left anterior oblique radiograph for the right L5 transforaminal injection. The triangle is formed by the iliac crest (IC), the inferior margin of the right transverse process (TP), and the right S1 superior articular process (SAP).B. Left anterior oblique radiograph for needle positioning. The needle tip is inferior and lateral to the right L5 pedicle (p = pedicle).C. Epidurography shows the outline of the right L5 nerve root sleeve (arrows).D. Epidurography for the left L4 transforaminal injection. Contrast is seen outlining the left L4 nerve root sleeve (arrows).E. Epidurography for the right S1 transforaminal injection (arrows).
Mentions: All procedures were performed in a sterile manner, and fluoroscopic guidance was used for the injections. The patients were placed prone on a fluoroscopy table and the C-arm was rotated to an ipsilateral oblique angle with respect to the suspected nerve root (L4, 5 or S1) (Fig. 1). Lidocaine (1%) was used for the cutaneous and needle tract local anesthesia. After placing a 22 gauge spinal needle at the appropriate level, epidurography with contrast agent was performed to evaluate the anatomy of the epidural space and the distribution of the injection fluid for ensuring that the desired compartment was adequately targeted. We used triamcinolone acetonide suspension 1 cc (TriamcinoloneR 40 mg [Apothecon, Princeton, NJ]) as the long-acting steroid and bupivacain hydrochloride 0.5 cc (MarcaineR 0.5% [Astra USA, Westborough, MA]) as the long-acting local anesthetic. After the procedure, the patient was observed in the short-stay unit for 0.5-1 hour depending on his or her condition. Ten of 68 patients underwent repeat injections; five patients were injected twice, two patients were injected three times, two patients were injected four times and one patient was injected five times. The interval between the injections was three weeks to six months. Although we usually waited 2-3 months before administering repeat injections, the repeat injection was performed in two patients only three weeks after the previous injection. In those patients, we used the half amount of the triamcinolon (20 mg) in the later injections. For the patients who had underwent repeated injections, the requirement of a successful outcome was also a patient satisfaction score greater than two and a pain reduction score greater than 50% at the last visit compared to the score before the injection.

Bottom Line: A successful outcome required a patient satisfaction score greater than two and a pain reduction score greater than 50%.There was no significant difference between the responders and non-responders in terms of the type, hydration and size of the HIVD, or an association with spinal stenosis (p > 0.05).MRI could play an important role in predicting the clinical outcome of non-surgical transforaminal ESI treatment for patients with lumbar HIVD.

Affiliation: Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, GangNeung, Korea.

ABSTRACT

Background:

Objective: We wanted to investigate the relationship between the magnetic resonance (MR) findings and the clinical outcome after treatment with non-surgical transforaminal epidural steroid injections (ESI) for lumbar herniated intervertebral disc (HIVD) patients.

Materials and methods: Transforaminal ESI were performed in 91 patients (50 males and 41 females, age range: 13-78 yrs) because of lumbosacral HIVD from March 2001 to August 2002. Sixty eight patients whose MRIs and clinical follow-ups were available were included in this study. The medical charts were retrospectively reviewed and the patients were divided into two groups; the successful (responders, n = 41) and unsatisfactory (non-responders, n = 27) outcome groups. A successful outcome required a patient satisfaction score greater than two and a pain reduction score greater than 50%. The MR findings were retrospectively analyzed and compared between the two groups with regard to the type (protrusion, extrusion or sequestration), hydration (the T2 signal intensity), location (central, right/left central, subarticular, foraminal or extraforaminal), and size (volume) of the HIVD, the grade of nerve root compression (grade 1 abutment, 2 displacement and 3 entrapment), and an association with spinal stenosis.

Results: There was no significant difference between the responders and non-responders in terms of the type, hydration and size of the HIVD, or an association with spinal stenosis (p > 0.05). However, the location of the HIVD and the grade of nerve root compression were different between the two groups (p < 0.05).

Conclusion: MRI could play an important role in predicting the clinical outcome of non-surgical transforaminal ESI treatment for patients with lumbar HIVD.

View Similar Images In: Results  - Collection
View Article: Medline Plus - Pubmed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=2626775&rFormat=json&query=null&req=5