A Prospective Comparison of CT-Epidurogram Between Th1-Transforaminal Epidural Injection and Th1/2-Parasagittal Interlaminar Epidural Injection for Cervical Upper Limb Pain

摘要

Background: Cervical epidural injections for treating neck and upper limb pain are performedby 2 methods: transforaminal and interlaminar. Many serious complications caused by inadvertentintravascular injection have been reported with the use of cervical transforaminal epidural steroidinjection through the anterior-lateral approach. Despite international practical guidelines that havebeen proposed, cervical transforaminal epidural injection is still less recommended than cervicalinterlaminar epidural injection.Objectives: The objective of this study is to introduce Th1-transforaminal epidural injection (Th1-TFEI) through the posterior-lateral approach, compare the injectate spread in Th1-TFEI with that ofTh1/2-parasaggital interlaminar epidural injection (Th1/2-pILEI), and clarify the clinical characteristicsof Th1-TFEI.Study Design: This research involved a prospective study of 30 patients receiving both Th1-TFEIand Th1/2-pILEI.Methods: Thirty patients with unilateral upper limb pain were enrolled for this prospective study.Th1-TFEI and Th1/2-pILEI were administered on each case in random order under fluoroscopy,and computed tomographic (CT) epidurograms were compared. Changes in circulatory dynamics,presence of Horner’s syndrome, changes in the Numerical Rating Scale (NRS-11), and adverse eventswere investigated.Results: Patients included 15 men and 15 women and included 24 cases of cervical spine diseaseand 6 cases with other upper limb pain. The Th1-TFEI group had significantly higher rates of “Th1root filling” (100%), “ventral spread” (70.0%), and “lateral limitation” (26.7%) compared to theTh1/2-pILEI group. In the Th1-TFEI group, cephalad spread averaged 2.97 vertebral bodies, reachingapproximately up to C6. The Th1/2-pILEI group had an average of 4.76 vertebral bodies, approximatelyup to C4. The 2 groups showed significant differences in cephalad spread. Horner’s syndromeappeared in the Th1-TFEI group at a rate of 56.7%, significantly higher than that in the Th1/2-pILEIgroup at 17.2%. The presence of Horner’s syndrome showed significant correlations with “ventralspread” and “spread up to C6.” There were no significant differences in NRS-11 improvement andchanges in circulatory dynamics between the groups. There were no major complications.Limitations: The components of injectate were standardized; however, the needle gauge numberswere varied. In addition, interpretation of the CT-epidurogram was not blinded. The sample size wassmall; therefore, multivariate analysis was not possible.Conclusions: CT-epidurogram comparison revealed that Th1/2-pILEI was not localized on theinjection side, and there was better dorsal spread – although ventral spread was small. Contrarily,Th1-TFEI was localized on the injection side, and better ventral spread was shown while cephaladspread was limited. We expected the addition of a sympathetic block effect suggested by the Horner’ssyndrome as well as the merits of the ventral spread. However, short-term clinical effects were equalto those of Th1/2 pILEI. In future research, we need to standardize the diseases to include and toincrease the number of cases to enable evaluation of clinical effectiveness.