title: Correlation between Epidurographic Contrast Flow Patterns and Clinical Effectiveness in Chronic Lumbar Discogenic Radicular Pain Treated with Epidural Steroid Injections Via Different Approaches.
abstract: BACKGROUND
  Epidural steroid injections are an accepted procedure for the conservative management of chronic backache caused by lumbar disc pathology. The purpose of this study was to evaluate the epidurographic findings for the midline, transforaminal and parasagittal approaches in lumbar epidural steroid injections, and correlating them with the clinical improvement.
  
  
  METHODS
  Sixty chronic lower back pain patients with unilateral radiculitis from a herniated/degenerated disc were enrolled. After screening the patients according to the exclusion criteria and randomly allocating them to 3 groups of 20 patients, fluoroscopic contrast enhanced epidural steroids were injected via midline (group 1), transforaminal (group 2) and parasagittal interlaminar (group 3) approaches at the level of the pathology. The fluoroscopic patterns of the three groups were studied and correlated with the clinical improvement measured by the VAS over the next 3 months; any incidences of complications were recorded.
  
  
  RESULTS
  The transforaminal group presented better results in terms of VAS reduction than the midline and parasagittal approach groups (P < 0.05). The epidurography showed a better ventral spread for both the transforaminal (P < 0.001) and the paramedian approaches (P < 0.05), as compared to the midline approach. The nerve root filling was greater in the transforaminal group (P < 0.001) than in the other two groups. The ventral spread of the contrast agent was associated with improvement in the VAS score and this difference was statistically significant in group 1 (P < 0.05), and highly significant in groups 2 and 3 (P < 0.001). In all the groups, any complications observed were transient and minor.
  
  
  CONCLUSIONS
  The midline and paramedian approaches are technically easier and statistically comparable, but clinically less efficacious than the transforaminal approach. The incidence of ventral spread and nerve root delineation show a definite correlation with clinical improvement. However, an longer follow-up period is advisable for a better evaluation of the actual outcom.
authors.affiliation: Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, India.
authors.forename: Ruchi
authors.initials: R
authors.lastname: Gupta
authors.affiliation: Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, India.
authors.forename: Saru
authors.initials: S
authors.lastname: Singh
authors.affiliation: Department of Anaesthesia, Post Graduate Institute of Medical Education and research, Chandigarh, India.
authors.forename: Sukhdeep
authors.initials: S
authors.lastname: Kaur
authors.affiliation: Department of Radiodiagnosis and Imaging, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, India.
authors.forename: Kulvinder
authors.initials: K
authors.lastname: Singh
authors.affiliation: Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, India.
authors.forename: Kuljeet
authors.initials: K
authors.lastname: Aujla
keywords: epidural steroid injection; fluoroscopy; midline interlaminar; parasagittal interlaminar; transforaminal