BACKGROUND: Transforaminal epidural steroid injections (TFESI) are commonly employed to treat lumbosacral radiculopathy. Despite anti-inflammatory properties, the addition of 3% hypertonic saline has not been studied.
OBJECTIVE: Compare the effectiveness of adding 0.9% NaCl (N-group) vs. 3% NaCl (H-group) in TFESI performed for lumbosacral radiculopathy.
METHODS: This retrospective study compared TFESI performed with lidocaine, triamcinolone and 0.9% NaCl vs. lidocaine, triamcinolone and 3% NaCl. The primary outcome was the proportion of patients who experienced a ≥ 30% reduction in pain on a verbal rating scale (VRS; 0-100) at 3 months. Secondary outcome measures included the proportion of patients who improved by at least 30% for pain at 1 and 6 months, and who experienced ≥15% from baseline on the Oswestry disability index (ODI) at follow-up.
RESULTS: The H-group experienced more successful pain outcomes than the N-group at 3 months (59.09% vs. 41.51%; P = .002) but not at 1 month (67.53% vs. 64.78%; P = .61) or 6 months (27.13% vs 21.55%: P = .31). For functional outcome, there was a higher proportion of responders in the H-group than the N-group at 3 months (70.31% vs. 53.46%; P = .002). Female, age ≤ 60 years, and duration of pain ≤ 6 months were associated with superior outcomes at the 3-month endpoint. Although those with a herniated disc experienced better outcomes in general with TFESI, the only difference favoring the H-group was for spondylolisthesis patients.
CONCLUSIONS: 3% hypertonic saline is a viable alternative to normal saline as an adjunct for TFESI, with randomized studies needed to compare its effectiveness to steroids as a possible alternative.
BACKGROUND: Thai Clinical Trials Registry ID TCTR 20231110006.

Lumbar radicular pain is a major public health and economic problem. It is among the most common reasons for professional disability. The most common cause of lumbar radicular pain is intervertebral disc herniation, which results from degenerative disc changes. The dominant pain mechanisms are direct pressure of the hernia on the nerve root and the local inflammatory process triggered by intervertebral disc herniation. Treatment of lumbar radicular pain includes conservative, minimally invasive, and surgical treatment. The number of minimally invasive procedures is constantly increasing, and among these methods is epidural administration of steroids and local anesthetic through a transforaminal approach (ESI TF). The aim of this research was to examine the effectiveness of ESI TF as measured by a visual analog scale (VAS) and the Oswestry Disability Index (ODI), depending on whether there is contact between the herniated intervertebral disc and the nerve root. In both groups of participants, there was a significant reduction in pain intensity, but there was no significant difference between the groups. In the group with disc herniation and nerve root contact, the only significant reduction was in pain intensity (p < 0.001). There were no significant differences in measurements in other domains of the ODI. In the group without disc herniation and nerve contact, there was a significant difference in all domains except weight lifting. In the group without contact, there was significant improvement after 1 month (p = 0.001) and 3 months (p < 0.001) according to the ODI, while there was no significant improvement in the group with contact. In addition, there were no significant differences in the distribution of participants based on the ODI and whether disc herniation and nerve contact was present. The results suggest that transforaminal epidural administration of steroids is a clinically effective method for treating lumbar radicular pain caused by intervertebral disc herniation in people with and without nerve root contact, without significant differences.

The aim of the study was to investigate the relationship between lumbar disc herniation and Goutallier classification (GC), lumbar indentation value, and subcutaneous adipose tissue thickness.
102 consecutive patients (59 female and 43 male) with lumbar back pain, numbness, tingling, or pain in the lower extremity indicating radiculopathy who had undergone lumbar magnetic resonance imaging (MRI) and had an intervertebral disc herniation in the L4-5 level, were included in the study. 102 patients who have undergone lumbar MRI in the same time period and have no disc herniation were chosen to be the control group and were selected so as to match the herniated group for sex and age. All these patients\' scans were re-interpreted regarding paraspinal muscle atrophy (using the GC), lumbar indentation value, and subcutaneous adipose tissue thickness in the L4-5 level.
The Goutallier score was higher in the herniated group, compared with the non-herniated group (p < 0.001). There was no statistical difference between herniated and non-herniated groups regarding lumbar indentation value (LIV) and subcutaneous adipose tissue thickness (SATT). A Goutallier score of 1.5 provided the highest sensitivity x specificity value to indicate the disc herniation according to the statistical results. The individuals with a Goutallier score of 2, 3, and 4 have 2.87 times more likely to have disc herniation in their MRIs than the ones with a score of 0 and 1.
Paraspinal muscle atrophy seems to be related to the presence of disc herniations. The cut-off value of GC to indicate the disc herniation in this study might be useful to predict the risk for disc herniation regarding the Goutallier score. The LIV and SATT measured in magnetic resonance images were randomly distributed between individuals with herniated and non-herniated groups, and statistically, no relationship was observed between these groups regarding these parameters.
The effect of the parameters studied in this research on disc herniations are expected to be an added value to the literature. The awareness of risk factors for intervertebral disc herniations might be used in preventive medicine to predict the risk and understand the tendency of an individual for disc herniations to occur in the future. Further investigations are needed to establish whether there is a causal relationship or correlation between these parameters and disc herniation.

BACKGROUND: Lumbar transforaminal epidural block (TFEB) is an effective treatment modality for radicular pain due to lumbar disc herniation (LDH). The addition of steroids is more effective than local anesthetic alone in TFEBs for patients with LDH. Moreover, the efficacy of TFEBs has been reported to be positively correlated with the volume of injectate. We hypothesized that high-volume TFEBs without steroids effectively alleviate axial back and radicular pain associated with LDH. This study compared the efficacy of high-volume TFEBs with vs. without steroids for the management of the axial and radicular pain caused by LDH.
METHODS: A total of 54 patients were randomly assigned to either group L or group D. Patients in group L received 8-mL injections of 0.33% lidocaine only. Patients in group D received 8-mL injections of 0.33% lidocaine with 5 mg of dexamethasone. The primary outcomes were pain intensity at baseline and 4 weeks after the procedure. The secondary outcomes included the change of functional disability between baseline and 4 weeks after the procedure, pain scores during injection, and adverse effects.
RESULTS: Both groups showed a significant reduction in axial and radicular pain and improvement in the functional status at the outpatient visit 4 weeks after TFEB. However, there were no significant differences between the groups in terms of changes in back pain (10.00 [20.00] vs. 10.00 [22.50]; P = 0.896) or radicular pain (5.00 [20.00] vs. 10.00 [12.50]; P = 0.871).
CONCLUSIONS: High-volume TFEBs with and without steroid administration yielded similar significant pain reductions and functional improvements among LDH patients 4 weeks after the procedure.

UNASSIGNED: This study aims to evaluate the effects of transforaminal epidural steroid injection (TFESI) on neuropathic pain (NP) in patients with chronic unilateral radiculopathy due to lumbar disc herniation (LDH).
UNASSIGNED: Between September 2018 and April 2019, a total of 61 patients who were diagnosed with unilateral/unilevel radiculopathy due to LDH and were scheduled for single-level TFESI were included in this study. The Numeric Rating Scale (NRS), modified Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and NP-Douleur Neuropathique 4 Questionnaire (DN4) were used before the procedure and at 1 hour, 3 weeks, and 3 months after the procedure.
UNASSIGNED: There was a significant decrease in the NRS and significant improvement in the ODI, BDI, and DN4 scores in all patients at all postprocedural timepoints (P < 0.05). The number of patients with NP decreased from 35 (60.3%) at baseline to 23 (41.2%) at 3 months (P = 0.001). The NRS scores were similar at 3 weeks and 3 months between the patients with and without NP (P > 0.05). The ODI scores were significantly higher at 3 months in the patients with NP than those without NP (P = 0.013). The BDI scores at baseline, 3 weeks, and 3 months were significantly higher in the patients with NP than those without NP (P < 0.001, P = 0.016, and P = 0.016, respectively).
UNASSIGNED: Our study results suggest that TFESI is an effective and safe method to decrease not only nociceptive but also NP component in patients with chronic radiculopathy due to LDH. Clinicians should keep in mind that NP is a risk factor that adversely affects the TFESI success and patients should be evaluated before the procedure.

UNASSIGNED: Although anterior cervical discectomy and fusion (ACDF) represents a standardized procedure for surgical treatment of a cervical herniated disc, several variables could affect patients\' clinical and radiological outcome. We evaluated the impact of sex, age, body mass index (BMI), myelopathy, one- or two-level ACDF, and the use of postoperative collars on functional and radiological outcomes in a large series of patients operated for ACDF.
UNASSIGNED: Databases of three institutions were searched, resulting in the enrollment of 234 patients submitted to one- or two-level ACDF from January 2013 to December 2017 and followed as outpatients at 6- and 12-month follow-up. The impact of variables on functional and radiological outcomes was evaluated using univariate and multivariate logistic regression analysis.
UNASSIGNED: At univariate analysis, female sex, higher BMI, two-level ACDF, and postoperative collar correlated with a significantly worse early and late Neck Disability Index (NDI). Multivariate analysis showed that male patients had a lower risk of worse early (P = 0.01) and late NDIs (P = 0.009). Patients with myelopathy showed better early NDI (P = 0.004). Cervical collar negatively influenced both early and late NDIs (P < 0.0001), with a higher risk of early nonfusion (P = 0.001) but a lower risk of late nonfusion (P = 0.01). Patients operated for two-level ACDF have a worse early NDI (P = 0.005), a worse late NDI (P = 0.01), and a higher risk of early nonfusion (P = 0.048). BMI and age did not influence outcome.
UNASSIGNED: Female sex, two-level surgery, and the use of postoperative collars significantly correlate with worse functional outcomes after one- or two-level ACDF.

Lumbar disc herniation (LDH) is associated with great morbidity and significant socioeconomic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients in whom pain and disability are unacceptable, surgical intervention provides effective clinical relief. Currently, there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome.
The aim of this study is to evaluate if prolonged symptom duration is correlated with less favorable outcome following surgery for LDH.
Consecutive series of patients from a single-center, multisurgeon, tertiary spine practice.
Consecutive series of patients who underwent surgery for LDH.
Oswestry Disability Index (ODI), EuroQol-5D (EQ-5D), and Visual Analog Scale (VAS) for back and leg pain (0-100).
Patients with a first-episode LDH were included. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their preoperative self-reported duration of leg pain: <3 months, 3 to 12 months, and >12 months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. Statistical significance level was set at p value <.01.
There were 2,144 patients included in the study, with complete 1-year follow-up on 1,694 patients (79%) and a reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain; however, this did not reach statistical significance (p=.039). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) 1 year after surgery (p=.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=.008) of increasing incidence of reoperation was found with increasing length of symptom duration.
Delayed surgical intervention results in inferior outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved significantly better outcome 1 year after surgery when compared to the other groups.

OBJECTIVE: To examine the impact of demographic, clinical, and genetic factors as well as herniated discs on 5-year development of disc degeneration in the lumbar spine, and to investigate associations between changes in lumbar degenerative findings and pain.
METHODS: In 144 patients with lumbar radicular pain or low back pain, we scored disc degeneration, herniated discs, and high-intensity zones in the posterior annulus fibrosus on lumbar magnetic resonance imaging (MRI) at baseline and 5-year follow-up. Genotyping (TaqMan assay) was performed for genes encoding vitamin D receptor (VDR), collagen XIα (COL11A), matrix metalloproteinase 1/9 (MMP1/MMP9), and interleukin 1α/1RN (IL-1α/IL-1RN). Associations were analyzed using multivariate linear regression adjusted for age, sex, smoking, body mass index, and baseline scores for degenerated discs and herniated discs (when analyzing impact of baseline factors) or for pain (when analyzing associations with pain).
RESULTS: Progression of disc degeneration over 5 years was significantly (p < 0.001) related to higher age and less disc degeneration at baseline, but not to sex, smoking, body mass index, herniated discs, or variants in the studied genes. No associations were identified between changes in disc degeneration or high-intensity zones and pain at 5-year follow-up. However, increased number of herniated discs over 5 years was associated with pain at rest (p = 0.019).
CONCLUSIONS: Age and disc degeneration at baseline, rather than genetic factors, influenced the 5-year development of disc degeneration in patients with lumbar radicular pain or low back pain. Development of herniated discs was related to pain at rest.

OBJECTIVE: The pain involved in the herniated discs could be generated by some mobility of the nerve roots during straight leg raising (SLR). SLR produces some movement of nerves, but the magnitude of this displacement needs to be thorough, that is why we have investigated lumbo-sacral nerve root displacement in the spinal canal during the passive straight leg raise (SLR).
METHODS: Fourteen cadavers underwent laminectomy to mark the nerve roots of L2-S1 with lead balls. X-rays were taken during different movements imposed on the body: bilateral hip extension, left SLR then right and bilateral SLR. By superimposing these images two by two, the displacement of the nerve roots is quantified numerically during the various SLR maneuvers with respect to the reference position corresponding to the bilateral hip extension.
RESULTS: The median range of the different nerve root movements ranged from 0.10 to 0.51 cm (p < 0.05 except for the L2 root) when the left SLR is applied, from 0.26 to 0.48 cm (p < 0.05) with the right SLR and from 0.30 to 0.65 cm (p < 0.05) with a bilateral SLR. No statistically significant relationship was found between age and movement value.
CONCLUSIONS: The lumbo-sacral nerve roots in the spinal canal region move statistically significantly in response to the clinically applied SLR test, except for L2 root during the left SLR. This movement is symmetric and greater when a bilateral SLR is applied. These anatomical results are correlated with those observed empirically in clinical practice.

BACKGROUND: The Low-Back Outcome Scale (LBOS) of Greenough and Fraser and the Oswestry disability index (ODI) were compared to the patient satisfaction index (PSI) in lumbar disc herniation (LDH) surgery.
METHODS: A total of 134 patients who underwent discectomy were followed through assessment of pre- and post-surgical satisfaction by the PSI, the LBOS, and the ODI. The LBOS were rated as satisfied if the outcomes were excellent or good and as dissatisfied if fair and poor. Considering the ODI, clinically satisfied was defined as a 13-point improvement from the baseline ODI scores. Phi (Φ) correlation analysis was used to study the correlation among the PSI, the LBOS and the ODI scores as proxy for patients\' satisfaction.
RESULTS: Mean age of patients was 48.9 years. Significant improvement from the pre- to post-operative ODI scores was observed. Post-surgical satisfaction based on the PSI, the ODI, and the LBOS were 70.9%, 76.8%, and 81.3%, respectively. Regarding patient satisfaction, there were weak associations between LBOS vs. PSI and ODI vs. PSI (Φ=-0.054, P=0.533) and (Φ=-0.129, P=0.136), respectively.
CONCLUSIONS: Our study showed that the ODI and the LBOS were not reflective of patients\' satisfaction after discectomy.