title: Epidural contrast flow patterns of transforaminal epidural steroid injections stratified by commonly used final needle-tip position.
abstract: OBJECTIVE
  To evaluate the relationship between commonly used final needle-tip positions and subsequent contrast flow and patient-reported pain relief in transforaminal epidural steroid injections (TFESIs).
  
  
  METHODS
  Retrospective cross-sectional study.
  
  
  METHODS
  Medical records of subjects (N = 83) having undergone a TFESI between January 2008 and January 2009 were reviewed to compare TFESIs using the superior-anterior (SA) vs. the superior-posterior (SP) quadrant.
  
  
  METHODS
  Outcome measures included ventral and dorsal epidural contrast flow as well as near-to-complete pain relief as measured by numerical rating scale pain score pre- and post-procedure.
  
  
  RESULTS
  SA TFESIs were associated with greater ventral epidural contrast flow as compared with SP TFESIs (100% vs 61.4%, P < 0.001). SA TFESIs with ventral epidural contrast flow were also associated with flow to a greater number of vertebral levels than SP TFESIs with ventral epidural contrast flow (41% vs 14.8%, P < 0.001). SP TFESIs were associated with greater dorsal epidural contrast flow than SA TFESIs (95.5% vs 43.6%, P < 0.05). SA TFESIs were also associated with a larger proportion of patients who achieved near-to-complete pain relief (P < 0.05) and greater reduction than SP TFESIs in post-procedure pain score relative to pre-procedure (3.3 vs 1.5, P < 0.01).
  
  
  CONCLUSIONS
  The evolution of TFESIs must balance both safety and efficacy. The efficacy of SA TFESIs is demonstrated to be superior to that of SP TFESIs with regards to ventral epidural flow and patient-reported pain relief. Further efforts should focus on demonstrating efficacy while optimizing safety.
authors.affiliation: Department of Anesthesiology & Critical Care Medicine, George Washington University Medical Center, Washington DC 20037, USA. mdesai@mfa.gwu.edu
authors.forename: Mehul J
authors.initials: MJ
authors.lastname: Desai
authors.forename: Binit
authors.initials: B
authors.lastname: Shah
authors.forename: Puneet K
authors.initials: PK
authors.lastname: Sayal
mesh_terms: D000767:Anesthesia, Epidural; D003430:Cross-Sectional Studies; D005471:Fluoroscopy / Q000379:methods; D006801:Humans; D007268:Injections, Epidural / Q000295:instrumentation / Q000379:methods*; D017116:Low Back Pain / Q000188:drug therapy*; D009339:Needles; D010147:Pain Measurement; D012189:Retrospective Studies; D013256:Steroids / Q000008:administration & dosage* / Q000627:therapeutic use
chemical_list: D013256:Steroids