背景:探讨一种新的超声(US)模式用于腰背痛(LBP)和L5根性疼痛合并上髂棘(HIC)患者的腰椎经椎间孔硬膜外注射(TFEI)。
方法:根据所接受的治疗,将一百一十一名患者回顾性地分为两组:新组,在L5和S1的上关节突之间使用矢状位斜入路接受US引导和透视(FL)控制的TFEI,以及对照组,接受美国指导的TFEI,采用传统的横向方法,结合FL确认。将造影剂分散到腰椎硬膜外腔的准确性设定为主要终点。辐射剂量,程序时间,数字评定量表(NRS)得分,改良Oswestry残疾问卷(MODQ)评分,不良事件,和抢救镇痛药的需求也被记录。采用广义线性混合模型(GLMMs)比较组间重复测量的变量,以个体混杂因素为协方差。
结果:TFEI的准确性在新组和对照组中分别为92.8%和65.2%,差异显著为26.7%(95%CI:15.4%,39.8%)两种模式之间(p<0.001)。一次注射后,与对照组相比,在新型组中观察到明显的疼痛缓解。新组手术时间(8.4±1.6分钟)短于对照组(15.8±3.5分钟)(p<0.001),辐射剂量较少(3047±5670vs.8808±1039μGy/m2,p<0.001)。重要的是,新型组L5感觉异常发生率较低。手术后1周达到新的和对照组之间的NRS评分的统计学差异(1(IQR:-1-3)与3(IQR:-1-7),p=0.006),而在1-(1(IQR:0-2)与1(IQR:-1-3),p=0.086)或3个月随访(0(IQR:-1-1)与1(IQR:0-2),p=0.094)。两组在随访期间显示相似的功能改善(F=0.103,p=0.749)。
结论:新的超声技术与常规横向进路相比,一次注射提供了更高的准确性针头放置和更好的疼痛缓解效果。因此,InsituationswheretheHICimposedlimitationsforTFEIperformanceonL5,thenewtechniqueshouldberecommendedtoconsiderincreasingaccurateputting,尽量减少辐射暴露,消耗程序时间,并降低神经损伤的风险。
BACKGROUND: To explore a novel ultrasound (US) modality for lumbar transforaminal epidural injections (TFEIs) in patients with low back pain (LBP) and L5 radicular pain combined with high iliac crest (HIC).
METHODS: One-hundred and forty-one patients were retrospectively stratified into two groups based on the treatment they received: novel group, receiving US-guided and fluoroscopy (FL)-controlled TFEIs using a sagittal oblique approach between the superior articular process of L5 and S1, and control group, receiving US-guided TFEIs with conventional transverse approach combined with FL confirmation. Accuracy of contrast dispersing into lumbar epidural space was set as the primary endpoint. Radiation dosages, procedure time, numeric rating scale (NRS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, adverse events, and rescue analgesic requirement were also recorded. The generalized liner mixed model (GLMMs) was employed to compare the repeatedly measured variables between groups, taking individual confounding factors as covariance.
RESULTS: The accuracy of TFEIs was 92.8% and 65.2% in novel and control group, with a significant difference of 26.7% (95% CI: 15.4%, 39.8%) between two modalities (p < 0.001). Significant pain relief was observed in novel group as opposed to control group after one injection. Procedure time in novel group (8.4 ± 1.6 min) was shorter than control group (15.8 ± 3.5 min) (p < 0.001) with less radiation dosage (3047 ± 5670 vs. 8808 ± 1039 μGy/m2, p < 0.001). Significantly, lower incidence of L5 paresthesia occurred in novel group. Statistical differences of NRS scores between the novel and control group were reached at 1 week after procedure (1 (IQR: - 1-3) vs. 3 (IQR: - 1-7), p = 0.006), while not reached at both 1- (1 (IQR: 0-2) vs. 1 (IQR: - 1-3), p = 0.086) or 3-month follow-up (0 (IQR: - 1-1) vs. 1 (IQR: 0-2), p = 0.094). Both groups showed similar functional improvement (F = 0.103, p = 0.749) during follow-up.
CONCLUSIONS: The novel sonographic technique provided superior accuracy needle placement and better pain-relieving effect through one injection as compared to the routine transverse approach. Consequently, in situations where the HIC imposed limitations for TFEIs performance on L5, the novel technique should be recommended to consider increasing accurate puncture, minimizing radiation exposure, consuming procedure time, and reducing the risk of neuraxial injury.