Exact lumbar anterior epidural injection via extreme lateral approach: A novel technique and clinical outcomes

Yıl 2025, Cilt: 9 Sayı: 3, 361 - 369, 31.12.2025

Buse Sarıgül , Ahmet Öğrenci , Levent Aydın , Goncagül Öndüç , Ali Fatih Ramazanoğlu , Sedat Dalbayrak

https://doi.org/10.29058/mjwbs.1790377

https://izlik.org/JA42NX94LA

Öz

Aim: Epidural injections have become popular for relieving back and radicular pain that is persistent to conservative therapy and is being widely used as an alternative to surgery. In this retrospective clinical study, we describe a new technique for direct anterior epidural space targeting via an extreme lateral approach for epidural injection and present 1-year outcomes of the intervention.
Material and Methods: In this clinical study, patients who had persistent back or radicular pain despite conventional treatment for 4 weeks were included. Anterior epidural injection via extreme lateral approach was performed in patients with degeneration of the lumbar spine, lumbar disc bulging or protrusion, and lumbar spinal stenosis. Visual Analogue Scale and Oswestry Disability Index scores were evaluated preoperatively, on postoperative 1st week, 1st month, and 12th month.
Results: 186 patients were included in the study. The mean age was 48.42±11.2. 72 (38.71%) patients were male, and 114 (61.29%) patients were female. The mean duration of symptoms was 16.4±14.13 weeks. The mean VAS score for back pain preoperatively was 7.92±1.77. The postoperative VAS for back were 2.1±1.29, 2.36±2.25, and 3.11±3.25 respectively for the 1st week, 1st month, and 12nd month.The average VAS for radicular pain was 4.49±1.91 preoperatively. Postoperative VAS were 1.89±2.68, 2.32±1.08, and 2.56±1.52 respectively for the 1st week, 1st month, and 12nd month. The ODI scores were 49.76±13.59, 11.69±5.35, 12.27±7.01, 14.3±7.32 respectively preoperatively, on the postoperative 1st week, 1st month, and 12th month.
Conclusion: The extreme lateral approach for anterior epidural injection is a safe and feasible technique method for the treatment of back and radicular pain.

Anahtar Kelimeler

Anterior epidural space , epidural injection , low back pain , radicular pain , extreme lateral

Ekstrem lateral yaklaşımla gerçek lomber anterior epidural enjeksiyon: Yeni bir teknik ve klinik sonuçlar

https://izlik.org/JA42NX94LA

Öz

Amaç: Epidural enjeksiyonlar, konservatif tedaviye dirençli bel ve radiküler ağrının giderilmesinde giderek daha sık kullanılan ve cerrahiye alternatif bir yöntem haline gelmiştir. Bu retrospektif klinik çalışmada, anterior epidural aralığın doğrudan hedeflenmesini sağlayan ekstrem lateral yaklaşım tekniği tanımlanmış ve 1 yıllık klinik sonuçlar sunulmuştur..
Gereç ve Yöntemler: Konservatif tedaviye rağmen 4 hafta boyunca devam eden bel veya radiküler ağrısı olan hastalar çalışmaya dahil edilmiştir. Lomber dejenerasyon, disk bulging veya protrüzyon ile lomber spinal stenozu olan olgularda aşırı lateral yaklaşım ile anterior epidural enjeksiyon uygulanmıştır. Ağrı ve fonksiyonel durum, operasyon öncesi ve operasyon sonrası 1. hafta, 1. ay ve 12. ayda Visual Analog Skoru (VAS) ve Oswestry Disability Index (ODI) ile değerlendirilmiştir.
Bulgular: Çalışmaya toplam 186 hasta dahil edilmiştir. Ortalama yaş 48,4±11,2 yıl olup, 72’si (%38,7) erkek ve 114’ü (%61,3) kadındır. Ortalama semptom süresi 16,4±14,1 hafta olarak saptanmıştır. Preoperatif bel ağrısı için VAS 7,9±1,8 iken, postoperatif 1. hafta, 1. ay ve 12. ayda sırasıyla 2,1±1,3; 2,4±2,3 ve 3,1±3,3 bulunmuştur. Radiküler ağrı için VAS preoperatif 4,5±1,9 iken, 1. hafta, 1. ay ve 12. ayda sırasıyla 1,9±2,7; 2,3±1,1 ve 2,6±1,5’e gerilemiştir. ODI skorları preoperatif 49,8±13,6 iken, postoperatif 1. hafta 11,7±5,4; 1. ay 12,3±7,0 ve 12. ay 14,3±7,3 olarak kaydedilmiştir.
Sonuç: Ekstrem lateral yaklaşım ile anterior epidural enjeksiyon, konservatif tedaviye dirençli bel ve radiküler ağrının tedavisinde güvenli ve uygulanabilir bir yöntem olup, kısa ve orta dönemde anlamlı klinik iyileşme sağlamaktadır.

Anahtar Kelimeler

Anterior epidural boşluk , epidural enjeksiyon , bel ağrısı , radiküler ağrı , ekstrem lateral

Kaynakça

• Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16(2):120-31. https://doi.org/10.1111/j.1525- 1497.2001.91141.x
• Urits I, Burshtein A, Sharma M, Testa L, Gold PA, Orhurhu V, et al. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep. 2019;23(3):23. https://doi.org/10.1007/s11916-019-0757-1
• Samanta A, Samanta J. Is epidural injection of steroids effective for low back pain? BMJ. 2004;328(7455):1509-1510. https://doi.org/10.1136/bmj.328.7455.1509
• Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11(8):1149-1168. https://doi.org/10.1111/j.1526-4637.2010.00908.x
• Lyu FJ, Cui H, Pan H, Mc Cheung K, Cao X, Iatridis JC, et al. Painful intervertebral disc degeneration and inflammation: from laboratory evidence to clinical interventions. Bone Res. 2021;9(1):7. https://doi.org/10.1038/s41413-020-00125-x
• McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J. 2005;5(2):191-201. https://doi.org/10.1016/j.spinee.2004.10.046
• Robecchi A, Capra R. L’idrocortisone (composto F); prime esperienze cliniche in campo reumatologico [Hydrocortisone (compound F); first clinical experiments in the field of rheumatology]. Minerva Med. 1952;43(98):1259-1263. PMID: 13036739.
• Sari S, Aydin ON, Guleser G, Kurt I, Turan A. Effect of transforaminal anterior epidural steroid injection on neuropathic pain, quality of sleep and life. Agri. 2015;27(2):83-88. https://doi.org/10.5505/agri.2015.91489
• McLain RF, Kapural L, Mekhail NA. Epidural steroids for back and leg pain: mechanism of action and efficacy. Cleve Clin J Med. 2004;71(12):961-970. https://doi.org/10.3949/ccjm.71.12.961
• Gordon J. Caudal extradural injection for the treatment of low back pain. Anaesthesia. 1980;35(5):515-516. https://doi.org/10.1111/j.1365-2044.1980.tb03835.x. PMID: 6446864.
• Kraemer J, Ludwig J, Bickert U, Owczarek V, Traupe M. Lumbar epidural perineural injection: a new technique. Eur Spine J 1997;6:357-361.
• Bogduk N. Epidural steroids. Spine (Phila Pa 1976). 1995;20(7):845-848. https://doi.org/10.1097/00007632-199504000-00021
• Rivera CE. Lumbar Epidural Steroid Injections. Phys Med Rehabil Clin N Am. 2018;29(1):73-92. https://doi.org/10.1016/j.pmr.2017.08.007
• Ansari S, Heavner JE, McConnell DJ, Azari H, Bosscher HA. The peridural membrane of the spinal canal: a critical review. Pain Pract. 2012;12(4):315-325. https://doi.org/10.1111/j.1533-2500.2011.00510.x
• Kobayashi S, Takeno K, Yayama T, Awara K, Miyazaki T, Guerrero A, et al. Pathomechanisms of sciatica in lumbar disc herniation: effect of periradicular adhesive tissue on electrophysiological values by an intraoperative straight leg raising test. Spine (Phila Pa 1976). 2010;35(22):2004-14. https://doi.org/10.1097/BRS.0b013e3181d4164d. PMID: 20959779.
• Helm Ii S, Benyamin RM, Chopra P, Deer TR, Justiz R. Percutaneous adhesiolysis in the management of chronic low back pain in post lumbar surgery syndrome and spinal stenosis: a systematic review. Pain Physician. 2012;15(4):E435-62. PMID: 22828693.
• Jacobs L, Vo N, Kang J. Identifying inflammatory targets for the biologic therapies for spinal pain. PM R. 2011;3(6 suppl 1):S12YS17.
• Nelemans PJ, de Bie RA, de Vet HC, Sturmans F. Injection therapy for subacute and chronic benign low back pain. Cochrane Database Syst Rev. 2000;(2):CD001824. doi: 10.1002/14651858.CD001824. Update in: Cochrane Database Syst Rev. 2007;(2):CD001824. https://doi.org/10.1002/14651858.CD001824.pub2. Update in: Cochrane Database Syst Rev. 2008;(3):CD001824. https://doi.org/10.1002/14651858
• Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336(23):1634-1640. https://doi.org/10.1056/NEJM199706053362303
• Benyamin RM, Manchikanti L, Parr AT, Diwan S, Singh V, Falco FJ, et al. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012;15(4):E363-404. PMID: 22828691.
• Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S. Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician. 2009;12(1):109-135. PMID: 19165299.
• Manchikanti L, Pakanati RR, Pampati V. Comparison of three routes of epidural steroid injections in low back pain. Pain Digest. 1999;9:277-85.
• Stout A. Epidural steroid injections for low back pain. Phys Med Rehabil Clin N Am. 2010;21:825Y834.
• Hopwood M, Abram S. Factors associated with failure of lumbar steroids. Reg Anesth. 1993;18:238Y243.
• Kim C, Choi HE, Kang S. Contrast spreading patterns in retrodiscal transforaminal epidural steroid injection. Ann Rehabil Med. 2012;36(4):474-479. https://doi.org/10.5535/arm.2012.36.4.474
• Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013;38(3):175-200. https://doi.org/10.1097/AAP.0b013e31828ea086
• Kwon WK, Kim AN, Lee PM, Park CH, Kim JH. Needle Tip Position and Bevel Direction Have No Effect in the Fluoroscopic Epidural Spreading Pattern in Caudal Epidural Injections: A Randomized Trial. Pain Res Manag. 2016;2016:4158291. https://doi.org/10.1155/2016/4158291
• Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245. PMID: 22622912.
• Desai M, Shah B, Sayal P. Epidural contrast flow patterns of transforaminal epidural steroid injections stratified by commonly used final needle-tip position. Pain Med. 2011;12:864Y870.
• Benny B, Azari P. The efficacy of lumbosacral transforaminal epidural steroid injections: a comprehensive literature review. J Back Musculoskelet Rehabil. 2011;24:67Y76.
• Buenaventura R, Datta S, Abdi S, Smith H. Systematic review of therapeutic lumbar transforaminal epidural steroid injections. Pain Physician. 2009;12:233Y251.
• Roberts S, Willick S, Rho M, Rittenberg J. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PMR. 2009;1:657Y668.
• Sariyildiz MA, Batmaz I, Yazmalar L, Gunes M, Turan Y. The effectiveness of antransforaminal epidural steroid injections on radicular pain, functionality, psychological status and sleep quality in patients with lumbar disc herniation. J Back Musculoskelet Rehabil. 2017; 30:265-270.
• Kamble PC, Sharma A, Singh V, Natraj B, Devani D, Khapane V. Outcome of single level disc prolapse treated with transforaminal steroid versus epidural steroid versus caudal steroids. Eur Spine J. 2016;25(1):217-221. https://doi.org/10.1007/s00586-015-3996-9
• Antibas PL, do Nascimento Junior P, Braz LG, Vitor Pereira Doles J, Módolo NS, El Dib R. Air versus saline in the loss of resistance technique for identification of the epidural space. Cochrane Database Syst Rev. 2014;2014(7):CD008938. https://doi.org/10.1002/14651858.CD008938.pub2
• Botwin KP, Natalicchio J, Hanna A. fluoroscopic guided lumbar interlaminar epidural injections: a prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Pain Physician. 2004;7:77–80
• Vorobeychik Y, Sharma A, Smith CC, Miller DC, Stojanovic MP, Lobel SM, et al; Standards Division of the Spine Intervention Society. The Effectiveness and Risks of Non-Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. Pain Med. 2016;17(12):2185-2202. https://doi.org/10.1093/pm/pnw091
• Ghai B, Vadaje KS, Wig J, Dhillon MS. Lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of low back pain with lumbosacral radicular pain: a double-blind, randomized study. Anesth Analg. 2013;117(1):219-227. https://doi.org/10.1213/ANE.0b013e3182910a15
• Candido KD, Raghavendra MS, Chinthagada M, Badiee S, Trepashko DW. A prospective evaluation of iodinated contrast flow patterns with fluoroscopically guided lumbar epidural steroid injections: the lateral parasagittal interlaminar epidural approach versus the transforaminal epidural approach. Anesth Analg. 2008;106(2):638-644, table of contents. https://doi.org/10.1213/ane.0b013e3181605e9b
• Jeong JS, Shim JC, Woo JP, Shim JH. Fluoroscopic analysis of lumbar epidural contrast spread after retrograde interlaminar ventral epidural injection (RIVEI). Korean J Anesthesiol. 2013;65(5):431-437. https://doi.org/10.4097/kjae.2013.65.5.431