诊断

Research Article

The Effectiveness of Transforaminal Epidural Injection for Discal Cyst of Lumbar Spine

Jung-Min Park1, Sun-Mi Lee2, Gun Woo Lee1

1Department of Orthopaedic Surgery, Armed Forces Yangju Hospital, Yangju, 482-863, Republic of Korea

2Department of Family Medicine, Myongji Hospital, Kwandong University College of Medicine, Goyang, Republic of Korea

Corresponding author: Gun Woo Lee, M.D., Tel: 82-31-863-1319; E-mail address: gwlee1871@gmail.com

 

 

Citation: Park JM, Lee SM, Lee GW. The Effectiveness of Transforaminal Epidural Injection for Discal Cyst of Lumbar Spine. J Minim Invasive Orthop, 2014, 1(1): e1. doi:10.15383/jmio.1.

Competing interests: The authors have declared that no competing interests exist.

Conflict of interest: None

Copyright: http://journalofnasopharyngealcarcinoma.org/Resource/image/20140307/20140307234733_0340.png2014 By the Editorial Department of Journal of Minimally Invasive Orthopedics. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 

Abstract: Prior literature does not provide clear data on the therapeutic outcome for each of the treatment methods studied for discal cyst (DC). The purpose of the current study evaluate the clinical outcomes of transforaminal epidural injection (TFEI) for DC in the lumbar spine, and to compare those to the outcomes of TFEI in treatment of disc herniation (DH) in the lumbar spine, using a prospective cohort study design. To our knowledge, this is the first report that evaluates the outcomes of TFEI for DC. Between June 2011 and February 2013, 87 patients who underwent TFEI for either DC or DH were enrolled in the current study. Clinical data using visual analogue pain scale (VAS) and the Oswestry Disability Index (ODI), were evaluated throughly. There was no significant difference in the demographic data between both groups. In DC group, two cases with TFEI had failed as indicated by showing no improvements in spite of two-times TFEI procedures. In DH group, four cases with TFEI procedure failed. There was no statistical differences in VAS and ODI scores between the two groups during the regular follow-up times post-TFEI. However, the VAS and ODI scores in DC group were slightly elevated after six months following TFEI procedure compared to those in DH group, although this increase was not statistically significance. TFEI might be a reasonable therapeutic option for patients with DC in lumbar spine. However, the possibility of gradually worsening radiating pain and functional status six months post-TFEI should be informed to the patients.

Key Words: Discal cyst, disc herniation, lumbar spine, transforaminal epidural injection, pain intensity, functional status

  

 

 

Introduction

Discal cyst (DC) in the lumbar spine is a rare disease entity that causes radiating pain of the lower extremities and/or back pain, similar to the symptoms present with lumbar spine disc herniation (DH) [1-4]. Various DC treatment options have shown favorable outcomes such as medication [1,5-7], percutaneous aspiration [1,7-11], injection treatment using several techniques [1,6,7,12], and surgical treatment [8,13-17]. However, no optimal therapeutic method has been established for DC due to the low prevalence of the disease. Previous studies on DC have had small sample sizes, retrospectively collected data, and short follow-up periods, with the study design ususally being either case report or case series [4,7-9,11-19]. Consequently, prior literature does not provide clear data on the therapeutic outcome for each of the treatment methods studied for DC.

Injection treatment has been recognized as a reasonable therapeutic method for managing DH in the lumbar spine [20-24]. There are several different techniques for injection treatment, of which, transforaminal epidural injection (TFEI) is considered to be one of the most effective methods [20,22,24,25]. Previous studies have demonstrated that TFEI has an outstanding ability to reduce the radiating pain caused by DH in the lumbar spine and to maintain this pain relief [20,22,24,25]. Moreover, it has also been cited as a valuable option for non-surgical management of DC in the lumbar spine [1-3,12]. Due to such encouraging findings from prior studies regarding DH, the authors thought that TFEI might also be a reasonable option for management of DC, but the therapeutic efficacy of TFEI for DC has not yet been determined.

Therefore, the authors intended to evaluate the clinical outcomes of

TFEI for treatment of DC in the lumbar spine, and compare those to the outcomes of TFEI in treatment of DH in the lumbar spine. This study may propose a baseline of the efficacy of TFEI as a treatment modality for DC. To the best of our knowledge, after reviewing the English-language medical literature, this is the first report that describes and compares the outcomes of injection treatment for DC of the lumbar spine using a prospective study design, relatively large sample size and long follow-up periods.

 

Materials and methods

Participants

This study was approved by the Institutional Review Board of the corresponding author. This was a comparative study of TFEI in patients with DC or DH in the lumbar spine using prospectively collected data. Patient enrollment for this study was started in June 2011. Between June 2011 and February 2013, a total of 87 patients underwent TFEI for either DC or DH, and the prospectively data collected from these patients were reviewed. Patients were assigned into the DC or DH group. In DC group, the DC located in the lumbar spine was detected by magnetic resonance images (MRI) of lumbar spine. In the DH group, DH in the lumbar spine was also detected by lumbar spine MRI. TFEI were performed in both patient group based on the following indications: (1) obvious findings of DC or DH by MRI of the lumbar spine; (2) development of unilateral radiating pain on the lower extremities and/or lower back pain due to DC or DH in the lumbar spine, which was confirmed by physical examination, MRI, and if necessary, additional tests such as electromyogram (EMG) and nerve conduction velocity (NCV), in order to exclude other disease entities causing similar symptoms in the lower extremities; and (3) no improvement in radiating pain on the lower extremities despite several conservative treatments for a minimum period of three months, where the conservative treatment included a combination of analgesics, anti-inflammatory drugs, and physical therapy.

Inclusion and exclusion criteria

Inclusion criteria for this study were as follows: (1) Patients for whom conservative treatment had failed for three months, after confirmation of DC or DH in the single-level lumbar spine and identifying symptoms or signs consistent with DC or DH; (2) Patients who were between 20 and 25 years of age; (3) Post-TFEI follow-up period of one or more years.

Exclusion criteria for the current study were as follows: (1) Injection not performed by the corresponding author; (2) Patient’s follow-up was limited to one year or less; (3) Disc herniation or discal cyst was present across two levels in the lumbar spine; (4) Patients who had undergone prior surgery in the lumbar spine (such as discectomy or lumbar fusion surgery); (5) Patients with abnormal activity of back muscles or diseases causing irregular ambulation such as parkinsonism and neuromuscular diseases.

These inclusion and exclusion criteria were applied to avoid the effects of confounding variables on study outcomes. Prior to injection, all patients were provided with information about the injection procedure, including type, timing, difficulty, and any potential complications. Informed consent was obtained from all patients.

TFEI procedure and post-injection protocol

TFEI was performed by one of the corresponding author, who is an orthopedic surgeon. The technique was standardized for all patients. An oblique view of the affected lumbar segment was obtained using fluoroscopic imaging. The skin was prepped with povidone-iodine and draped in a sterile fashion. The 22-gauge, 3.5-inch spinal needle was advanced toward the target position below the pedicle and into the “safe triangle” using intermittent flurorscopy for guidance (Fig. 1) [26]. Proper needle placement was confirmend in both the anteroposterior and lateral images. Next, 1 mL of the contrast medium (OmnipaqueTM, Nycomed, Ireland) was injected, and neurogram and pain provocation were observed (Fig. 2). Once an adequate contrast flow was observed, 4 mL of a mixture consisting of 40mg triamcinolone (Kena­log®, Bristol Myers Squibb Co. Princeton, NJ) and 1% lidocaine was injected.

Figure 1. The safe triangle (black arrow), which indicates the safe area of needle placement which was targeted in the TFEI, is composed of a roof made up the pedicle, a base that corresponds to the exiting nerve root, and the lateral border of the vertebral body.

Figure 2. Neurogram (black arrow) could be detected after injection of 1mL contrast medium after needle advancement into the safe triangle.

Both groups of patients were operated on the same surgical wards and treated using the same postoperative protocols. After injection, patients were put into the supine position for one hour and allowed to ambulate. All patients were discharged from the hospital on the same day. Patients were not permitted to sit for long periods of time or perform immoderate exercise for two weeks. Upon conclusion of this two week period, patients were allowed to resume normal activities, including heavy lifting.

Data collection and analysis

Patient characteristics, including age, sex, clinical presentation, and co-morbidities such as diabetes mellitus, obesity, and smoking history, and clinical data were prospectively collected in a database.

Clinical outcomes were evaluated using a visual analogue scale (VAS) and the Oswestry disability index (ODI), which were obtained by one research coordinator preoperatively, every week for one month postoperatively, and at three months, six months, and one year postoperatively. Patients were not allowed to review their previous scores. The VAS and ODI qustionnaires were filled out by the patients prior to visiting the surgeon during their regular follow-up visits. The questionnaires, chart data, clinical records, and radiologic imaging were analyzed by an orthopaedic surgeon who was not otherwise involved in this study.

Statistical analysis

Statistical analysis was conducted using the paired t-test and the Wilcoxon Rank test, using SAS version 9.1.3 (SAS Institute Inc., Cary, NC, USA). P-values < 0.05 were considered to be statistically significant. Numerical values are expressed as mean ± SD.

  

Results

Demographic data

Out of the 87 patients who underwent TFEI during the study period, 76 patients (18 in the DC group and 58 in the DH group) met the inclusion and exclusion criteria and were enrolled in this study. No patient was lost to follow-up (Fig. 3). There was no significant difference in the demographic data between both groups, including age, gender, duration of symptoms, or smoking (Table 1). All enrolled patients had either DC or DH in a single-level lumbar segment. In the DC group, there were 3 in L3-4, 10 in L4-5, and 5 in L5-S1. In the DH group, there were 6 in L3-4, 32 in L4-5, 20 in L5-S1. The affected level of pathology was not statistically different between the two groups (Table 1).

Figure 3. Flow diagram for enrolled patients.

Clinical outcomes

Pre-injection pain intensity (VAS for both radiating pain and back pain) and functional status (ODI) were not statistically different (P = 0.65) (Table 2). There was no statistical differences in VAS and ODI scores between the two groups during the regular follow- up times

post-TFEI (Table 2).

 

 

Table 1. Demographic Data of the Enrolled Patients

 

DC group

(n =18)

DH group

(n =58)

P

Age(year)

20.4±1.1

20.6±1.3

0.81

Sex (male/female)

11/7

36/22

0.25

Height (cm)

169.5 ± 4.3

171.4 ± 6.4

0.57

Weight (kg)

69.7 ± 7.7

72.7 ± 10.7

0.43

BMI (kg/m2)

24.3 ± 2.3

24.7 ± 2.8

0.79

Follow-up period (month)

14.9±2.2

17.4±4.6

0.38

Symptom duration (month)

3.7 ± 1.4

5.2 ± 2.3

0.17

Smoking

 

 

0.31

   Smoker

5 (38.5%)

21 (36.2%)

 

   Non-smoker

13 (61.5%)

37 (63.8%)

 

Affected level

 

 

0.56

   L3-4

3 (16.7%)

6 (10.3%)

 

 L4-5

10 (55.6%)

32 (55.2%)

 

 L5-S1

5 (27.7%)

20 (34.5%)

 

Values in data cells represent mean ± SD (standard deviation).

DC, discal cyst; DH, disc herniation; BMI, body mass index

 

Table2. Summarized Data of Both Groups about Clinical Outcomes

Clinical Parameters

DC group

(n= 18)

DH group

(n = 58)

P

VAS for radiating pain

Pre-operative

7.1 ±0.3

7.3 ±0.4

0.63

1 month postoperative

2.1 ±0.4

2.2±0.4

0.61

  3 months postoperative

2.0±0.5

1.8±0.6

0.45

  6 months postoperative

2.1 ±0.9

2.0±0.8

0.57

  1 year postoperative

2.5±0.8

2.1±1.0

0.12

VAS for back pain

Pre-operative

   4.3 ±1.5

4.1±1.3

0.35

1 month postoperative

   1.2 ±0.3

1.0 ±0.5

0.32

  3 months postoperative

   1.0 ±0.2

0.8 ±0.5

0.43

  6 months postoperative

   1.2 ±0.6

1.1 ±0.7

0.51

  1 year postoperative

   1.5 ±0.7

1.6 ±1.0

0.47

ODI score

  Pre-operative

26.5 ±5.1

25.1 ±4.7

0.51

1 month postoperative

8.1 ±2.7

9.5 ±2.1

0.62

  3 months postoperative

7.3 ±0.9

7.5 ±0.8

0.60

  6 months postoperative

8.7±1.4

8.5±0.6

0.53

  1 year postoperative

16.0±2.5

10.5 ±2.8

0.07

Values in data cells represent mean ± SD (standard deviation).

DC, discal cyst; DH, disc herniation; VAS, visual analogue scale; ODI, oswestry disability index

 

There was no case of technical failure during the TFEI procedure in the DC group. However, 2 cases (11.1%) with TFEI had failed, meaning that the radiating pain in the lower extremities had not improved in spite of two-times TFEI procedures. These two patients ultimately underwent surgical excision of the discal cyst. The mean VAS score for radiating pain and back pain decreased from 7.1 ± 0.3 preoperatively to 2.5 ± 0.8 at one year after surgery, and from 4.3 ± 1.5 preoperatively to 1.5 ± 0.7 at one year after surgery, respectively. The mean ODI score also decreased from 26.5 ± 5.1 preoperatively to 16.0 ± 2.5 at one year after surgery (Table 2). These improvements in the VAS and ODI scores were statistically significant (P = 0.001, < 001 and < 0.001, respectively), but the VAS and ODI scores were only slightly elevated after six months following TFEI procedure; this increase was not statistically significance (Figs. 4A-C).

In the DH group, there were two cases of technical failure during TFEI; two patients could not undergo the TFEI procedure because of lancinating leg pain during the needle advancement, so they received an interlaminal epidural block instead. In the DH group, four of the cases (6.9%) who had undergone the TFEI procedure failed as indicated by showing no improvements in the lower extremitiy radiating pain in spite of two-times TFEI procedures. These four patients finally underwent surgical discectomy. In the 56 cases except two cases of technical failure, the mean VAS score for radiating pain and back pain decreased from 7.3 ± 0.4 preoperatively to 2.1 ± 1.0 at one year after surgery, and from 4.1 ± 1.3 preoperatively to 1.6 ± 1.0 at one year after surgery, respectively. The mean ODI score also decreased from 25.1 ± 4.7 preoperatively to 10.5 ± 2.8 at one year after surgery (Table 2). These improvements in the VAS and ODI scores were statistically significant (P = 0.001, 001, and < 0.001, respectively) (Figs. 4-6).

 

Figure 4. Mean VAS in back pain by time points. The VAS was collected at each follow-up time. Error bars represent standard deviations. (There was a statistically significant difference between scores in baseline and each follow-up time.)

 

Figure 5. Mean VAS in radiating pain of lower extremity by time points. The VAS was collected at each follow-up time. Error bars represent standard deviations. (There was a statistically significant difference between scores in baseline and each follow-up time.)

 

Figure 6. Mean ODI scores by time points. The ODI was collected at each follow-up time. Error bars represent standard deviations. (There was a statistically significant difference between scores in baseline and each follow-up time.)

 

Discussion

The current study has three main findings. First, TFEI would produce similar therapeutic outcomes in pain improvement and functional status in patients with both DC and DH. Our results showed that out of all the patients who had undergone TFEI, 2 / 18 (11.1%) DC patients and 4 / 58 (6.9%) DH patients had unsuccessful results without any significant difference between both groups. These patients ultimately underwent a surgical procedure for pain management. Second, a similar improvement was observed for both groups only up to six months following TFEI. After six months after TFEI, the clinical parameters (pain intensity and functional status) in the DC group gradually worsened compared to those in the DH group, although there was no significant difference between both groups. Finally, TFEI might be a reasonable treatment option for DC patients with radiating pain on the lower extremities and/or lower back pain who do not respond with conservative treatments such as medication and physical therapy. It is important, however, to inform these patients of the possibility that the radiating pain and functional status could increase six months after the TFEI procedure.

DC was recently defined as a clinical entity by Chiba et al [27]. DC in the lumbar spine is a rare disease entity whose clinical symptoms may be indistinguishable from the symptoms present with DH [1,3]. The disease usually manifests as a unilateral single nerve root lesion. Due to its extremely low prevalence and incidence, only a few articles have studied the pathophysiology, prevalence, and morphometric evaluation of DC. Thus, concrete treatment guidelines and alternative therapies have not been determined for DC. Some therapeutic methods for DC, such as medication, aspiration, injections, and surgical excision, have been reported with diverse outcomes [1,5,9-11,13,15,16]. Takeshima et al. [4] reported spontaneous regression of symptomatic DC with conservative treatments including medication and physical therapy. However, the spontaneous regression of DC was based on a case report. The possibility of spontaneous regression using only medication could be helpful when treating patients without severe or aggravating neurological conditions. Direct aspiration of the cyst using several techniques is a therapeutic measure that has been introduced [1,9,10]. Among the several aspiration techniques studies, CT-guided aspiration has been shown to be a useful treatment option for the treatment of symptomatic DC. The benefits of percutaneous CT-guided aspiration of the cyst include low infection rate, procedure performed under local anesthesia, and short recovery time. However, the procedure has inherent problems, such as having difficulty in approaching the target lesion, the possibility of dural puncture, radiation exposure, as well as possibility of disease recurrence [1,7-10]. The true disease recurrence rate after CT-guided aspiration remains unknown due to the rare use of the procedure till date. Some studies have argued that surgical excision should be the treatment of choice [1,7,11,13,15-17]. Most DC patients who were managed surgically, either using an open or endoscopic method, have reported good outcomes. However, surgical complications also arise, such as infections, anesthesia-related problems, bleeding, root injury, and disease recurrence. On the other hand, injection treatment using various techniques is a relatively simple and safe procedure [20,22,25], as compared to aspiration and surgical excision. In addition, injection treatment under fluoroscopic guidance has been reported to be efficacious. However, the effectiveness of injection treatment has not been determined for DC due to rare prevalence and the paucity of clinical studies. As a result, it is impossible to predict the results of injection treatment and to determine its therapeutic efficacy in the treatment of DC.

Initially, injection treatment was introduced for treating DH in the lumbar spine, and numerous articles have demonstrated its effectiveness for the treatment of DH [20-25]. Of the injection techniques, TFEI has several benefits as follows: (1) It can be performed at any spinal levels, even those that do not have accessible interlaminar spaces [21,24,28]; (2) Compared to other approach techniques, TFEI has the theoretical advantage of being the most target-specific and providing greater ventral epidural spread [20-22,26]; (3) This procedure carries a low risk of inadvertent dural puncture [25,26,28]; and (4) Most importantly, TFEI has demonstrated therapeutic efficacy for the treatment of DH in the lumbar spine, in numerous clinical trials [20-25,28,29]. Although there has been established of its effectiveness for DH in lumbar spine, the paucity of clinical studies for DC could make its performance for DC to hesitate. Based on the current study, the authors think that TFEI could be a reasonable treatment method for DC patients with radiating pain and/or back pain who do not respond to medication and physical therapy. Also, it is important to inform these patients of the possibility to aggravate six months after the TFEI procedure.

Limitations

This study had some limitations. This was a prospectively comparative study with a relatively small sample size and short follow-up period. A greater number of patients should be studied over an extended follow-up period to better understand how TFEI affects the outcomes of treatment for DC. In addition, randomized case-control trials should be performed when possible. Despite these limitations, the results included most of the 76 patients who underwent TFEI for the treatment of DC and DH, without patient follow-up loss. Specifically, this study included a larger pool of DC patients (18 patients) without loss to follow-up, compared to previous articles. Another strength of the study was that the data were obtained from a homogenous population with respect to age, gender, sports and physical activity, as the research occurred at an armed forces hospital. This homogeneous population reduce the risk of confounding on outcome variables.

 

Conclusions

The current study demonstrated that TFEI might be a reasonable therapeutic option for patients with DC in lumbar spine with radiating pain and/or back pain, especially for those who do not respond to medication and physical therapy. However, the possibility of gradually worsening radiating pain and functional status six months post-TFEI should be informed to the patients.

 

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