Dissertation on

“FUNCTIONAL OUTCOME OF SELECTIVE TRANSFORAMINAL

NERVE ROOT BLOCK FOR LUMBAR RADICULOPATHY IN

INTERVERTEBRAL DISC PROLAPSE”

submitted to

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY

CHENNAI – 600032

RegNo : 221712153

In partial fulfilment of regulations for award of the degree of

M.S. DEGREE

BRANCH – II

DEPARTMENT OF ORTHOPAEDIC SURGERY

GOVT. KILPAUK MEDICAL COLLEGE

CHENNAI

MAY - 2020
 CERTIFICATE - I

This is to certify that this dissertation entitled ‘‘FUNCTIONAL

OUTCOME OF SELECTIVE TRANSFORAMINAL NERVE ROOT

BLOCK FOR LUMBAR RADICULOPATHY IN

INTERVERTEBRAL DISC PROLAPSE’’ is a record of bonafide

research work done by Dr. M. KABILAN, Post Graduate student under

my guidance and supervision in partial fulfillment of regulations of The

Tamilnadu Dr. M.G.R. Medical University for the award of M.S. Degree

Branch II (Orthopaedic Surgery) during the academic period from 2017

to 2020, in the Department of Orthopaedics, Government Royapettah

Hospital & Govt. Kilpauk Medical College, Kilpauk, Chennai-600010

Prof. Dr. R. BALACHANDRAN, Prof. Dr.S.VEERAKUMAR,

M.S Ortho., D. Ortho., M.S Ortho.,
Professor of Orthopaedics, Professor and H.O.D.,
Department Of Orthopaedics, Department Of Orthopaedics,
Govt. Royapettah Hospital, Govt. Kilpauk Medical College,
Govt. Kilpauk Medical College, Chennai-600 010.
Chennai-600 010.

Prof. Dr .P.VASANTHAMANI
M.D, D.G.O, MNAMS, DCPSY, MBA
DEAN
Govt. Kilpauk Medical College
Chennai-600010
 DECLARATION

I, Dr. M. KABILAN, solemnly declare that this dissertation

titled ‘‘FUNCTIONAL OUTCOME OF SELECTIVE

TRANSFORAMINAL NERVE ROOT BLOCK FOR LUMBAR

RADICULOPATHY IN INTERVERTEBRAL DISC PROLAPSE’’ is

a bonafide record of work done by me in the Department of Orthopaedics,

Govt. Royapettah Hospital under the aegis and expert guidance of

Prof. Dr. R. BALACHANDRAN, M.S.Ortho. D. Ortho., Professor of

Orthopaedics, Department of Orthopaedic Surgery, Government

Royapettah Hospital, Govt. Kilpauk Medical College, Chennai 600010.

This dissertation is submitted to Tamilnadu Dr. M.G.R. Medical

University, Chennai 600032 towards fulfillment of regulations for the

award of M.S. degree Branch II (Orthopaedic surgery).

Place : Chennai Signature

Date : (Dr. M. Kabilan)

SIGNATURE OF UNIT CHIEF

Prof. Dr. R. BALACHANDRAN,
M.S Ortho., D. Ortho.,
Professor of Orthopaedics,
Department Of Orthopaedics,
Govt. Royapettah Hospital,
Govt. Kilpauk Medical College,
Chennai-600 010.
 ACKNOWLEDGEMENT

I express my utmost gratitude and heartfelt thanks to my respected

teacher and guide, Prof. Dr. R. BALACHANDRAN, M.S. Ortho., D. Ortho.,

Professor of Orthopaedics, Department of Orthopaedics, Govt. Royapettah

Hospital, Chennai, for the exemplary guidance, inspiration and encouragement

he has rendered at every stage of this study. Without his supervision and

constant help this dissertation would not have materialized.

I express my heartfelt thanks and gratitude to a very kind and

encouraging Head of the Department Prof. Dr. S. VEERAKUMAR,

M.S. Ortho., Professor of Orthopaedics, Department of Orthopaedics, Govt.

Kilpauk Medical College, Chennai-600010 for his excellent guidance and

encouragement during this study.

I sincerely acknowledge with gratitude, the guidance and persistent

encouragement given to me by my teachers, Prof. Dr. S. SENTHIL KUMAR

M.S.Ortho, D. Ortho., former H.O.D, Department of Orthopaedics, Govt.

Royapettah Hospital, Chennai, Prof. Dr. M. ANTONY VIMAL RAJ, Professor

of Orthopaedics, GovtKilpauk Medical College, Chennai, and

Prof. Dr.V.THIRUNARAYANAN M.S. Ortho., former Professor of

Orthopaedics, Govt. Royapettah Hospital, Chennai.

I sincerely thank Dr. B. THANIGAIARASU M.S. Ortho.,

Dr. R. AMARNATH M.S. Ortho., Dr. AGNIRAJ M.S. Ortho., D.Ortho.,

Dr. T. SIVABALAN M.S.Ortho., Dr. M. VIKRAM M.S. Ortho,

Dr. F. FAKHRUDDIN . M.S. Ortho., Dr. C. PALANIKUMAR M.S. Ortho.,

Dr. M. KARTHIKEYAN M.S. Ortho., Dr . K.SRIDHAR M.S Ortho,

Assistant Professors, Department of Orthopaedics, Govt. Royapettah Hospital,

Chennai, Dr. M. ArunmozhiRajan M.S. Ortho., Dr. R. Prabhakar Singh

M.S.Ortho., Dr. G. Mohan M.S. Ortho, DNB Ortho., Dr. S. Prabhakar,

M.S.Ortho, D. Ortho. DNB Ortho., Dr. S. Makesh Ram M.S.Ortho,

D. Ortho, DNB Ortho., , Dr. Karu Shanmugha Karthikeyan M.S.Ortho.,

Dr. R. Manojkumar M.S. Ortho, Assistant Professors, Department of

Orthopaedics, Govt. Kilpauk Medical College, Chennai who have put countless

hours in guiding me throughout the preparation of this dissertation.

My sincere thanks to Prof. Dr. P. Vasanthamani, M.D.DGO. MNAMS,

DCPSY, MBA, Dean, Govt. Kilpauk Medical College, Chennai, for permitting

meto utilize the clinical materials of the hospital.

Lastly I express my heartfelt thanks to all my patients who form the main

content for this study and my sincere thanks to my postgraduate colleagues,

intern students, hospital staff who have been of very big support throughout this

study. I express my utmost gratitude to my family members and friends who

have stood by me throughout the study and above all the ALMIGHTY for his

grace.
PLAGIARISM REPORT
 CERTIFICATE – II

This is to certify that this dissertation work titled “FUNCTIONAL

OUTCOME OF SELECTIVE TRANSFORAMINAL NERVE ROOT

BLOCK FOR LUMBAR RADICULOPATHY IN

INTERVERTEBRAL DISC PROLAPSE” is a bonafide research work

of the candidate Dr. M. KABILAN with Registration Number

221712153 for the award of M.S. Degree in the branch of

ORTHOPAEDIC SURGERY. I personally verified the Urkund.com

website for the purpose of plagiarism check. I found that the uploaded

thesis file contains Introduction to Conclusion pages and 19 percentage of

plagiarism in this dissertation.

CO - GUIDE & SUPERVISOR SIGN

WITH SEAL
 TABLE OF CONTENTS

SL No. CONTENTS PAGE No.

1. INTRODUCTION 1

2. AIM OF THE STUDY 4

3. REVIEW OF LITERATURE 5

4. APPLIED ANATOMY 11

5. PATHOPHYSIOLOGY 14

6. CLINICAL EVALUATION & 19

INVESTIGATIONS

7. MANAGEMENT 27

8. MATERIALS AND METHODS 45

9. OBSERVATION AND RESULTS 57

10. CASE ILLUSTRATIONS 69

11. DISCUSSION 81

12. CONCLUSION 89

13. BIBILOGRAPHY

14. ANNEXURE
• Patient Proforma
• Consent Form
• Abbreviations
• Master Chart
INTRODUCTION
 INTRODUCTION

Lumbar disc prolapse characterized by symptomatic disc herniation

or typical sciatica is a major challenge for health care. The lifetime

prevalence of radiculopathy due to a herniated lumbar disc is estimated to

be around 4%in females and 5%in males.(1) A diagnosis of lumbar

radiculopathy was made based on medical history, symptoms, and

standardized physical examination. One third of all patients with lumbar

disc syndrome had been previously hospitalized with it and one fifth of

the patients had undergone lumbar surgery.

Lumbar radiculopathy is radiating pain in the lower limbs through

narrowed intervertebral foramen by a herniated intervertebral disc due to

degenerative changes and thickening of the ligamentum flavum,

zygapophyseal joint and surrounding soft tissues. In addition to

mechanical compression, causes of radicular pain in degenerative lumbar

spinal stenosis are difficult to explain by one theory. Suggested causes

include inflammatory changes around nerve root, venous congestion and

haematogenous disability. In the management of radicular pain produced

by spinal stenosis, injected steroid is expected to contribute to pain

reduction by interrupting the synthesis of prostaglandins, blocking

conduction of nociceptive c fibers and controlling edema around the

nerve root. While early surgery in carefully selected patients with

1
discogenic radiculopathy can achieve rapid relief, potential disadvantages

of surgery include risks of infection, discitis, recurrence, nerve root injury

and anesthetic complications could be avoided by epidural

block.(2) Among the different techniques of intraspinal steroid injection

such as transforaminal, interlaminar, and caudal epidural steroid

injections, selective nerve root block (SNRB) is a highly target-oriented

procedure with good efficacy in patients with Lumbar disc disease. The

corticosteroid is injected directly near the dorsal root ganglion and the

inflamed nerve root it is possible to inject toward the anterior extradural

space of the nerve root related to symptoms.(3,4)

In 1972, Kambin introduced endoscopic intervertebral discectomy

by posterolateral approach, defining the Kambin's triangle as the site to

approach the intervertebral disc. The Kambin's triangle is defined as a

right triangle over the dorsolateral disc. The hypotenuse is the exiting

nerve root, the base (width) is the superior border of the caudal vertebra

and the height is the dura/traversing nerve root. This approach can protect

the epidural and nervous system and prevent chronic nerve edema,

epidural bleeding and epidural scarring.5. Thus, safety can be secured

when this site is used for epidural injection. Currently, the subpedicular

approach is the most common method used clinically. In this method, the

injection needle is progressed towards the safe triangle under the inferior

2
surface of the pedicle to locate the superolateral spinal nerve related to

symptoms. This location is favoured because agents can be injected into

the anterior extradural space, i.e. the inflammatory site between the back

of the herniated intervertebral disc and the anterior nerve root dural

sleeve.5The risk of damaging duramater is decreased, as the injection

needle goes through the border of the lateral upper intervertebral

foramen.

However, Murthy et al. reported that the Adamkiewicz artery

(AKA artery) runs through the safe triangle and injection at this site

might transfer agents within the artery or directly damage

vessel.Furthermore, potential complications associated with surgery such

as recurrence, cerebrospinal fluid leakage, hematoma, and infection can

be avoided by SNRB.6The efficacy of SNRB in acute LDH has been

quoted variedly in previous studies ranging from 30%to 80%

In this context, the purpose of this study was to elucite the

functional outcome of transforaminal epidural block using the

subpedicular approach in patients complaining of lumbar radicular pain,

and to investigate the short-term effects upto a period of 1 year and

possible complications during injection.

3
AIM &OBJECTIVE
 AIM OF THE STUDY

To study the short term effects and advantage of transforaminal

selective nerve root block using steroids and local anaesthethic for lumbar

radiculopathy in intervertebral disc disease for patients who failed

medical line of management.

OBJECTIVE

• To compare the severity of pain in the patient using the Visual

Analog Score (VAS) pre injection and post injection period.

4
REVIEW OF
LITERATURE
 REVIEW OF LITERATURE

John et al.– (2002) showed that After an average follow-up period

of 1.4 years, the group receiving transforaminal epidural steroid

injections had a success rate of 84%, as compared with 48% for the group

receiving trigger-point injections (P< 0.005). They concluded that

fluoroscopically guided transforaminal injections serve as an important

tool in the nonsurgical management of lumbosacral radiculopathy

secondary to a herniated nucleus pulposus.

Cooper G et al (2004)–demonstrated the effectiveness of

transforaminal epidural steroid injections in patients with degenerative

lumbar scoliotic stenosis and radiculopathy obtained follow-up on 52

(85.2%) of 61 included patients. They defined a successful outcome as a

patient who was both satisfied with his or her results and experienced at

least a 2-points improvement in NRS, Summary Pain, and Summary

Function scores. Using these criteria for success, 59.6% of our patients

had a successful outcome at one week post-injection, 55.8% at one month

post-injection, 37.2% at one year post-injection, and 27.3% had a

successful outcome at two years post-injection (p < 0.01).They concluded

that Fluoroscopic transforaminal epidural steroid injections appear to be

an effective nonsurgical treatment option for patients with degenerative

lumbar scoliotic stenosis and radiculopathy and should be considered

before surgical intervention.

5
 Pfirrmann et al. ( 2001) showed that the contrast material

distributions of selective nerve root blocks (SNRBs) in 36 patients (13

women, 23 men; mean age, 52 years; age range, 22-88 years) were

graded by two radiologists in conference as type 1 (tubular appearance),

type 2 (nerve root visible as filling defect), or type 3 (nerve root not

visible). These patterns were correlated with pain reduction after 15

minutes and 2 weeks (with a visual analogue scale of 100-mm length). In

addition, 30 nerve roots were injected with iodine-containing contrast

material and blue dye in three cadaveric specimens. Radiographs were

compared with anatomic sections. Therapeutic SNRB is effective in

sciatica, but early response does not predict the effect after 2 weeks. Type

1 injections are more painful than type 2 injections.

Lee JW, Kim SH, Lee IS, et al. (2006) published Therapeutic

effect and outcome predictors of sciatica treated using transforaminal

epidural steroid injection - Transforaminal epidural steroid injections

were performed in 248 patients from June 2003 to May 2004. Fifty-six

patients (33 women, 23 men; mean age, 53.3 years; age range, 30-83

years) were included. Therapeutic effects were evaluated 2 weeks after

injection. The possible outcome predictors were as follows: intra

epineural or extra epineural injection, saddle-type distribution pattern

(contrast material distributed rostrally to the epidural portion of the

preganglionic nerve root) or not saddle type, cause of sciatica (spinal

stenosis vs herniated disk), patient age, patient sex, and duration of

6
sciatica (acute or subacute [< 6 months] vs chronic [> 6 months]). The

relationships between possible outcome predictors and therapeutic effects

were analyzed. Statistical analysis was performed using Fisher's exact

test, the chi-square test, and multiple logistic regression analysis.

Woong et al( 2011)Forty-three (76.8%) of the 56 patients achieved

a satisfactory result 2 weeks after transforaminal epidural steroid

injection. Nineteen (65.5%) of the 29 patients treated by intra epineural

injection and 24 (88.9%) of the 27 patients treated by extra epineural

injection achieved a satisfactory result, and this difference was

significantly different (p < 0.05). Other possible predictors of a better

outcome were identified--that is saddle-type pattern of contrast

distribution, a herniated disk and sciatica of less than 6 months' duration.

Multiple regression analysis showed that the only factor significantly

associated with outcome was the type of injection (p = 0.04, odds ratio:

5.01).Transforaminal epidural steroid is an effective tool for managing

sciatica, and an extra epineural injection may be a predictor of a better

outcome for sciatica treated using transforaminal epidural steroid.

Helio et al(1987)- A sample of 8000 persons representative aged

30 or over-was asked to come for examination, and 7217 (90%)

participated. A diagnosis of lumbar disc syndrome based on medical

history, symptoms, and standardised physical examination was made for

5-1% of the men and for 3-7%- of the women. Half of these patients were

assessed to be in need of medical care, over 80% of which was

7
considered to be adequately met. One third of all patients with lumbar

disc syndrome had been previously hospitalised for that syndrome, and

one fifth of the patients had undergone lumbar surgery. At least slight

disability was found in almost 60% of the patients, though severe

functional limitations were rare. About 6% of the population's work

disability was estimated to be attributable to lumbar disc syndrome.

Jacobs WCH, van Tulder M, Arts M, et al. (2011) concluded

that In general, there is evidence that early surgery in patients with

sciatica provides for a better short-term relief of leg pain as compared to

prolonged conservative care, but the evidence is low quality because of

the fact that only one trial investigated this properly. No significant

differences were found between surgery and usual conservative care in

any of the clinical outcomes after 1 and 2 years, but the evidence is of

very low quality. The scarcity of studies as well as the limited quality of

the studies does not support the choice for any timing in our current

guidelines.

Solberg TK, Nygaard .P, Sjaavik K, Hofoss D, IngebrigtsenT.

In his prospective study of 180 patients, we report the frequency of and

the risk factors for getting worse after first time lumbar microdiscectomy.

Follow-up time was 12 months. Primary outcome measure was the

Oswestry disability index, assessing functional status and health-related

quality of life. Of the patients 4% got worse. Independent risk factors of

deterioration were a long duration of sick leave and a better functional

8
status and quality of life prior to operation. We conclude that the risk of

deterioration is small, but larger if the patient has been unable to work

despite relatively small health problems. This study also demonstrates

that changes in instrument scores should be reported, so that an accurate

failure rate can be assessed.

Goupille P et al(1998)- In his study, investigators have reported

the presence of proteolytic enzymes from disc culture systems and disc

tissue extracts in degenerated human intervertebral discs, especially

collagenase-1 (MMP-1) and stromelysin-1 (MMP-3). The matrix

metalloproteinases are regulated by specific inhibitors (tissue inhibitors of

metalloproteinases, or TIMPS), cytokines (interleukin-1), and growth

factors. This field of application is of particular interest because

conventional treatments are disappointing in chronic low back pain.

Clinical trials with specific inhibitors of metalloproteinases are beginning

in osteoarthritis.

Narozny M et al( 2003) - The objective of this study was to

investigate the clinical effectiveness of nerve root blocks (i.e.,

periradicular injection of bupivacaine and triamcinolone) for lumbar

monoradiculopathy in patients with a mild neurological deficit. They

have retrospectively analysed 30 patients (29-82 years) with a minor

sensory/motor deficit and an unequivocal MRI finding (20 disc

herniations, 10 foraminal stenosis) treated with a selective nerve root

block. Based on the clinical and imaging findings, surgery

9
(decompression of the nerve root) was justifiable in all cases. Twenty-six

patients (87%) had rapid (1-4 days) and substantial regression of pain,

five required a repeat injection. 60% of the patients with disc herniation

or foraminal stenosis had permanent resolution of pain, so that an

operation was avoided over an average of 16 months (6-23 months)

follow-up. Nerve root blocks are very effective in the non-operative

treatment of minor mono radiculopathy and should be recommended as

the initial treatment of choice for this condition.

Benzon H.(2013) concluded that Epidural steroid injections for

low back pain and lumbosacral radiculopathy concluded that Non-

surgical treatments of back pain may have prolonged and lasting benefit.

Epidural steroid injections is one of the non-operative managements of

back pain. These injections are recommended in patients with signs and

symptoms of nerve root irritation. Relief of pain is attributed to the anti-

inflammatory effect of the steroid. Patients with acute radiculopathy have

better response compared to patients with chronic symptoms.

Improvement may not be noted until 6 days after the injection. The

depression of the hypothalamic-pituitary-adrenal (HPA) axis lasts 3

weeks.

10
FUNCTIONAL ANATOMY
&
PATHOLOGY
 FUNCTIONAL ANATOMY& PATHOLOGY

The normal anatomy of the spine is usually described by dividing

up the spine into three major sections. The cervical, the thoracic and the

lumbar spine. (Below the lumbar spine is a bone called the sacrum, which

is part of the pelvis). Each section is made up of individual bones, called

vertebrae. There are 7 cervical vertebrae, 12 thoracic vertebrae and 5

lumbar vertebrae.

An individual vertebra is made up of several parts. The body of the

vertebra is the primary area of weight bearing and provides a resting

place for the fibrous discs which separate each of the vertebrae. The

lamina covers the spinal canal, which is the large hole in the center of the

vertebra through which the spinal nerves pass. The paired transverse

processes are oriented 90 degrees to the spinous process and provide

attachment for back muscles.

11
 Inteervertebraal discs coonsist of an outer fibrous rring, the annulus
a

fibrosus disc
d intervvertebraliss, which surroundss an innerr gel-like center,

the nucleuus pulpossus. The annulus

a fibrosus
f coonsists off several layers

(laminae) of fibroccartilage made

m up of
o both typpe I and ttype II co
ollagen.

Type I iss concentrrated towaard the ed

dge of the ring, w
where it prrovides

greater strrength. Thhe stiff lam

minae can
n withstandd compresssive forcees. The

fibrous inntervertebrral disc coontains thee nucleus pulposus and this helps
h to

distribute pressure evenly accross the disc.

d This prevents tthe develo
opment

of stress concentraations whhich could

d cause damage
d too the underlying

vertebrae or to theirr endplatees. The nucleus pulpposus conttains loosee fibers

suspendedd in a muucoprotein gel. The nucleus of

o the discc acts as a shock

absorber, absorbingg the imppact of thee body's activities

a and keepiing the

two vertebbrae separrated. It iss the remnant of the notochordd.

12
 There is one disc between each pair of vertebrae, except for the

first cervical segment, the atlas. The atlas is a ring around the roughly

cone-shaped extension of the axis (second cervical segment). The axis

acts as a post around which the atlas can rotate, allowing the neck to

swivel. There are 23 discs in the human spine 6 in the neck (cervical)

region, 12 in the middle back (thoracic) region and 5 in the lower back

(lumbar) region Discs are named by the vertebral body above and below.

For example, the disc between the fifth and sixth cervical vertebrae is

designated C5-6

FUNCTION OF INTERVERTEBRAL DISC

The intervertebral disc functions to separate the vertebrae from

each other and provides the surface for the shock-absorbing gel of the

nucleus pulposus. The nucleus pulposus of the disc functions to distribute

hydraulic pressure in all directions within each intervertebral disc under

compressive loads. The nucleus pulposus consists of large vacuolated

notochord cells, small chondrocyte - like cells, collagen fibrils, and

aggrecan, a proteoglycan that aggregates by binding to hyaluronan.

Attached to each aggrecan molecule are glycosaminoglycan (GAG)

chains of chondroitin sulfate and keratan sulfate. Increasing the amount

of negatively charged aggrecan increases oncotic pressure, resulting in a

shift of extracellular fluid from the outside to the inside of the nucleus

13
pulposus. The amount of glycosaminoglycans (and hence water)

decreases with age and degeneration.The intervertebral discs provide a

strong attachment between the vertebral bodies. They are important to

supply movement between neighbouring vertebrae but they also have a

bouncy deformability that allows them to serve as shock absorbers.

EPIDEMIOLOGY / ETIOLOGY

Lower back pain is severely common in general population, but

lumbar radiculopathy has only been reported with incidence of 3 to

5%. The annual prevalence of disc related sciatica in general

population is estimated at 2.2%. Lumbar radiculopathy is a disorder

that commonly arises with significant socioeconomical consequences.

The discal origin of a lumbar radiculopathy incidence is around 2%.

Out of a 12.9% incidence of low back complaints within working

population 11% is due to lumbar radiculopathy. The prevalence of

lumbosacral radiculopathy is 9.9% to 25%.

HERNIATION

A herniated disc (also called bulged, slipped or ruptured) is a

fragment of the disc nucleus that is pushed out of the annulus, into the

spinal canal through a tear or rupture in the annulus. Discs that become

herniated usually are in an early stage of degeneration. The spinal canal

14
has limited space, which is inadequate for the spinal nerve and the

displaced herniated disc fragment. Due to this displacement, the disc

presses on spinal nerves causing Chemical infammatory mediators –

Phospholipase A2, Interleukin 1 & 6, TNF alpha,Nitric oxide, stimulation

of nociceptive c fibres which produces pain .

A spinal disc herniation, commonly referred to as a slipped disc,

can happen when unbalanced mechanical pressures substantially deform

the annulus fibrosus, allowing part of the nucleus to obtrude. These

events can occur during peak physical performance, during trauma or as a

result of chronic deterioration, typically accompanied with poor posture

and has been associated with a Propiono bacterium acnes infection. Both

the deformed annulus and the gel-like material of the nucleus pulposus

can be forced laterally or posteriorly, distorting local muscle function,

and putting pressure on the nearby nerve. This can give the symptoms

typical of nerve root entrapment. These symptoms can vary between

15
parasthaesia, numbness, chronic and/or acute pain, either locally or along

the dermatome served by the entrapped nerve, loss of muscle tone and

decreased homeostatic performance. The disc is not physically slipped

rather it bulges usually in just one direction.

STAGES OF DISC PROTUSION

RADICULOPATHY

Radiculopathy is caused by compression or irritation of the

nerves with resultant pain, weakness, and/or sensor impairment in the

affected nerve root may be from direct trauma or from chemical

irritation to the affected nerve root. This can be due to mechanical

16
 compression of the nerve by a disk herniation, a bone spur

(osteophytes) from osteoarthritis or from thickening of surrounding

ligaments. As people age, their spines are subject to increasing

degeneration which can cause herniated discs and similar problems

such as spinal stenosis leading to lumbar radiculopathy.

CAUSES

• Herniated disc with nerve root compression (90%).

• Lumbar stenosis

• Tumours (less often)

• Underlying diseases like infections (Imaging is indicated here)

• Lateral recess stenosis and radiculitis.

17
 RISK FACTORS

• Age (peak 45-64 years)

• Smoking

• Mental stress

• Strenuous physical activity (frequent lifting)

• Driving (vibration of whole body)

INDICATIONS OF SCIATICA / SYMPTOMS

• Unilateral leg pain greater than low back pain, leg pain follows a

dermatomal pattern

• Pain traveling below knee to foot or toes

• Numbness and paraesthesia in the same area

• Straight leg raise positive which induces more pain

Clinical presentation depends on the cause of the radiculopathy

and which nerve roots are being affected. Also important is the nature

(sharp, dull, piercing, throbbing, stabbing, shooting, burning) and

localisation of the pain. Some patients reports beside radicular leg pain

also neurological signs such as paresis, sensory loss or loss of

reflexes. If not present, this is not a radiculopathy.

18
Nerve
D
Dermatom
mal area Myoto
omal areaa R
Reflexive changes
c
Root
L1 Innguinal reegion Hip flex
xors
L2 A
Anterior m
mid-thigh Hip flex
xors
Hip flex
xors and Diminished or absent
L3 D
Distal anterior thigh
knee ex
xtensors patelllar reflex
M
Medial low
wer Knee ex
xtensors annd Diminished or absent
L4
leeg/foot ankle do
orsiflexorss patelllar reflex
Hallux extension
e
Diminished or absent
L5 L
Lateral legg/foot and ank
kle plantarr
achillles reflex
flexors
Ankle plantar
p
Diminished or absent
S1 L
Lateral side of foot flexors and
achillles reflex
evertorss

19
 CLINICAL TEST

STRAIGHT LEG RAISING TEST LASUEGE TEST

CROSSED LEG RAISING TEST FEMORAL NERVE STRETCH

TEST

BOW STRING SIGN

20
 INVESTIGATIONS

PLAIN RADIOGRAPHS

Plain radiograph is the simplest and most readily available. AP and

Lateral views are needed x-ray features of a herniated lumbar disc reveals

vacuum sign, Loss of lumbar lordosis, Radiolucent defect, Presence of

nitrogen gas accumulations in annular and nuclear degenerative fissures

typical central vacuum phenomenon and gas collection that fills large

neo-cavity occupying both the nucleus and annulus indicative of

advanced disc degeneration.

Oblique views are needed to visualize Spondylolisthesis and lysis and

hypertrophic changes around foramina.

21
Lateral flexion/ extension views to check for instability

y Ferguson View is taken by20 degrees caudocephalic AP to

visualize the “far out syndrome,” which is the fifth root

compression by a large transverse process of the L5 vertebra

against the ala of the sacrum.

y Angled caudal views to visualize the facet or laminar pathological

conditions

y Indirect Signs

◦ Disc space narrowing

◦ Sclerosis of end plates

◦ Osteophytes

◦ Traction spur

◦ Vacuum Sign

◦ Direct signs - Translational abnormalities on dynamic films

X ray- Signs of Instability

22
 White And Punjabi Classification For Lumbo Sacral Instability

Element Point Value

Anterior elements destroyed or unable to function 2

Posterior elements destroyed or unable to function 2

Disruption of costovertebral articulations 1

Radiographic criteria

Saggital plane displacement >2.5mm 2

Relative sagittal plane angulation >5 degrees 2

Spinal cord or cauda equina damage 2

Dangerous loading anticipated 1

*Total of 5 or more unstable

COMPUTED TOMOGRAPHY

CT aids in the assessment of fractures, Spondylolysis, preoperative

planning and alternative for assessing a patient with instrumentation if

planned for surgery.

Advantages

• Extremely useful, highly accurate & non-invasive tool in the

evaluation of spinal disease.

• It provides superior imaging of cortical and trabecular bone

compared with MRI.

23
 • It provides contrast resolution and identify root compressive

lesions such as disc herniation.

• It also helps to differentiate between bony osteophyte from soft

disc.

• It helps to diagnose foraminal encroachment of disc material due to

its ability to visualize beyond the limits of the dural sac and root

sleeves.

Limitations

y It cannot differentiate between scar tissue and new disc herniation.

y It does not have sufficient soft tissue resolution to allow

differentiation between annulus and nucleus.

MRI

y MRI is the most accurate and sensitive modality or the diagnosis of

subtle spinal pathology and it is the test of choice. It allows direct

visualization of herniated disc material and its relationship to

neural tissue including intrathecal contents

Its advantages over CT

y Imaging the intervertebral disc

y Directly images neural structures

y Shows the entire region of study (i.e., cervical, thoracic or lumbar).

y Ability to image the nerve root in the foramen

y It can also visualize the disc protrusion zones

24
DISC PROTUSION ZONES

Limitations

y Showing abnormal anatomy in asymptomatic patient

y Clinical exam is paramount

T1 weighted image and T2 weighted image

IMAGE
T1 weighted image T2 weighted image
SEQUENCE

FAT Bright Less bright

FLUID Dark Bright
Study the pathologic
Study the anatomy of
changes in spine
USES cord and nerve roots
Differentiate the nucleus
and spinal cord
from annulus fibrosus

25
 T1 weeighted im
mage T2 weighted
d image

Normal Lumbar
L M
MRI Vs L
Lumbar M
MRI showiing
herniaated disc

26
TREATMENT

The treatment options are usually used in combination

y Conservative

(i) Bed rest

(ii) Medications

(iii) Physical therapy

(iv) Lifestyle modifications

(v) Chiropractic manipulation

(vi) Lumbo-sacral orthosis

(vii) Selective injections

(viii) Intradiscal Electrothermal Therapy ( IDET )

(i) Bed Rest

No data to suggest that bed rest alters the natural history of lumbar

disc herniations or improves outcomes. It is advised rest for 2 days in

semi fowlers or lateral position with hip and knee in flexion though no

proven hypothesis was appreciated.

27
 (ii) Medications
Various groups of analgesics were used for pain relief though none
give permanent relief of pain.
◦ Selective COX-2 inhibitors
◦ Preferential COX-2 inhibitors
◦ Nonselective
y Acetaminophen
y Opioids
y Steroids
y Muscle relaxants
y Anti depressants
y Anti Seizure drugs
(iii) Physical Therapy
Physical therapies such asexercises, back schooland other modalities such
as IFT, SWD, TENS, Traction were even advisable.

28
(iv) Exercises

Exercises found to be better than medical care alone. Ideally

Flexion-based isometric exercises appear to have the most support in the

literature. They offer benefit by decreasing local muscle spasm and

stabilizing the spine. But have to begin when acute pain diminishes.

General rules for Exercise

• Do each exercise slowly

• Hold the exercise position for a slow count of five

• Start with five repetitions and work up to ten

• Relax completely between each repetition

• Do the exercises for 10 minutes twice a day

• Care should be taken when doing exercises that are painful

• A little pain when exercising is not necessarily bad

• If pain is more or referred to the legs the patient may have

overdone it

• Do the exercises every day without fail

29
 (V) TENS

Transcutaneous electrical nerve stimulation acts by release of

endogenous analgesic endorphin. In TENS, Central nervous system

process in which a control center is altered to block transmission of pain.

Deyo RA et al studies showed that ‘TENS is no different from a placebo’.

(VI) Intermittent Pelvic Traction

Intermittent pelvic traction aids by distracting the lumbar vertebrae

and enlargement of the intervertebral foramen and there by creation of a

vacuum to reduce herniated discs. It also places the Posterior longitudinal

ligament under tension to aid in reduction of herniated discs and causes

relaxation of muscle spasm. It also frees the adherent nerve roots.

However it does not alter natural history of disease.

(VII) Back School

Back school is the education in proper posture and body mechanics

.It is helpful in returning the patient to the usual level of activity. It is

given based on Individual or Group instruction. Quality and quantity of

information provided may vary widely.

30
(VIII) Lumbo-Sacral Orthosis

The Purpose of LSO is to stabilize and immobilize the lumbar

spine. Its usefulness in lumbo sacral pathologies are vertebral body

fracture, spondylolysis with spondylolisthesis and postoperative support.

However their use in low back pain is doubtful.

y Not prescribed in

◦ Lack of compliance on the part of the patient

◦ Creating psychological dependence

◦ Validating the disability

◦ Weakening of postural back and abdominal muscles (not

proven)

y Does not alter natural history of the disease

31
 SELECTIVE INJECTIONS

Epidural Block

An epidural steroid injection is performed to help reduce the

inflammation and pain associated with nerve root compression. Nerve

roots can be compressed by a herniated disc, spinal stenosis and bone

spurs. The goal of the epidural steroid injection is to help lessen the

inflammation of the nerve root. The epidural space is located above the

outer layer surrounding the spinal cord and nerve roots. An epidural

steroid injection goes into the epidural space directly over the compressed

nerve root.

Most epidural steroid injections are placed between the lamina,

known as interlaminar epidural steroid injections. The lamina is portions

of the bones on the back side of the spine that are arranged like shingles.

The needle is aimed upwards toward the head and passes between two

adjacent laminae. Another type of injection is a transforaminal steroid

injection. In this case, the needle passes along the course of the nerve and

enters the spine from a more diagonal direction.

32
 Interrlaminar Epidurall Steroid

Epidurall Steroids

Steeroid injecction reduuces pain

n by inteerruption of syntheesis of

prostaglanndins bloccking connduction of

o nocicepptive C fi
fibres deccreases

edema rouund the neerve.

33
Reason foor interlaaminar faiilure

Druug adminnistered in posteerior inteerlaminar space doesn’t

d

effectively reach thhe exitingg nerve ro

oot througgh the epiidural spaace that

contains loose areeolar connnective tissue,

t sem
miliquid fat, lymp
phatics,

arteries annd extensiive plexuss of veins. In transfooraminal bblock the exiting

nerve rooot is selecttively targgeted throu

ugh the inntervertebrral forameen with

the usage of radio iodine

i conntrast.

TRANSF
FORAMIN
NAL APP
PROACH
H

Kambin's trianglee approach

Kam
mbin's triaangle is deefined as a right triaangle overr the dorso
olateral

disc. Thee hypotenuuse is thee exiting nerve

n root, the basse (width)) is the

superior border off the cauudal verteebra, and the heigght is thee dura/

traversingg nerve rooot. Nervee root can

nal is the space thaat the nerv
ve root

34
occupies from where it is visible to where it leaves the intervertebral

foramen. The canal is divided into the entrance, middle and exit zone.

The space occupied by the spinal nerve outside the exit zone is called the

far lateral zone, were we target in transforaminal block.

Subpedicular approach

In the subpedicular approach, the agents are injected at the exit

zone as the distal site of the nerve root canal

Safe triangle – subpedicular approach

• Bounded superiorly by inferior border of pedicle

• Laterally by the outer vertical border of the foramen

• Diagonally by the exiting nerve root

35
 • Significanntly decrreased riisk of dural peenetration since

superolateeral aspect of spinall nerve is approache

a ed

• Caution: segmentall artery off Adamkieewicz is aat risk esp

pecially

in upper lumbar
l verrtebra

Thhe most dangeroous radicculomedullary arteery in lumbar

transforam
minal injeection is the
t AKA artery. Inn 80% off healthy people,
p

when pennetrating the spinaal canal, the

t arteryy enters thhe interveertebral

foramen between left T9 (9th

( thoraacic vertebbra) and L1 (1st lumbar

vertebra).. Howeverr, care shoould be taaken becauuse in aboout 20% of

o cases

it enters thhe interveertebral forramen bettween L2 and

a L4. The main trrunk of

the AKA
A enters thhe medial spinal caanal throuugh eitherr the mid or the

rostral poortion of the foram

men. Therre it passses througgh the prroximal

portion off the dorsaal root gannglion and

d the ventrral root complex.

36
DRUGS

Drugs of choice

• Methylprednisolone

• Triamcinolone suspension

Mechanism of Action

Corticosteroid injection acts by interruption of synthesis of

prostaglandins, blocking conduction of nociceptive C fibres decreases

edema round the nerve.

Concentration of drugs

• Methylprednisolone 20 or 40 mg

• Triamcinolone 20 or 40 mg

Anesthetics

• 2.0% to 4.0% preservative-free lidocaine

• 0.5% to 0.75% bupivacaine

Radio opaque agents

Iohexol-N,N´-Bis(2,3-dihydroxypropyl)-5-[N-(2,3-dihydroxypropyl)-

acetamido]-2,4,6-triiodoisophthalamide, is a non-ionic, water-soluble

radiographic contrast medium with a molecular weight of 821.14 .

Iohexol available in various concentrations forms for intra thecal

injections such as 180mg/ml, 240mg/ml, 300mg/ml is recommended for

the examination of the lumbar, thoracic and cervical regions in adults by

lumbar or direct cervical injection and is slightly hypertonic to CSF.

37
LIGNOCAINE

It is a versatile LA, good both for surface application as well as

injection and is available in a variety of forms. Injected around a nerve it

blocks conduction within 3 min, whereas procaine may take 15 min;

also anaesthesia is more intense and longer lasting. Vasodilatation

occurs in the injected area. It is used for surface application, infiltration,

nerve block, epidural, spinal and intravenous regional block anaesthesia.

Cross sensitivity with ester LAs is not seen.

Side Effects
• Early central effects of lidocaine are depressant, i.e.
drowsiness, mental clouding, dysphoria, altered taste and
tinnitus.
• Overdose causes muscle twitching, convulsions, cardiac
arrhythmias, fall in BP, coma and respiratory arrest like
other LAs.
• Direct intravenous injection could cause cardiac symptoms.
RISKS IN TRANSFORAMINAL BLOCK
• Direct injection into nerve root – Intense pain, damage of
nerve
• Injection into blood vessel
• Nerve root sleeve cyst – Injection produces headache
• Injection into fluid sac surrounding spinal nerves –
numbness of both legs immediately
• Arachnoiditis – resulting in chronic back and lower limb
pain
38
OPERATIVE TREATMENT

Prerequisites

• Surgeon sure of diagnosis

• Patient feels that pain is debilitating enough to warrant

surgery

• Understand that surgery does not stop the pathological

process

• Nor does it restore disc to normal state

• May only provide symptomatic relief

• Physiotherapy and activity restrictions may be needed

post op

• Patient selection is the Key

• Extending below the knee

• Present for at least 6 weeks

• Decreased by rest, anti-inflammatory medication or even

epidural steroids

• Returned to the initial levels after a minimum of 6 to 8

weeks of conservative care

• Physical signs: Positive SLR, neurological deficits

• Imaging should confirm the level of involvement

consistent with the patient's examination

39
Indications

Absolute

y Bladder and bowel involvement: The cauda equina syndrome

y Increasing neurological deficit

Relative

y Failure of conservative treatment

y Recurrent sciatica

y Significant neurological deficit with significant SLR reduction

y Disc rupture into a stenotic canal

y Recurrent neurological deficit

Surgical Options

y Standard discectomy

y Limited Discectomy

y Microsurgical Lumbar discectomy & Endoscopic discectomy

y Additional Exposure

◦ Hemi laminectomy

◦ Total Laminectomy

◦ Facetectomy

y Percutaneous Discectomy

y Chemonucleolysis

y Arthrodesis

y Disc replacement
40
STANDARD DISECTOMY
Positioning

y Prone position

y With bolsters

y Knee chest position

y Allows abdomen to hang free

◦ minimizing epidural venous dilation and bleeding

y Lateral position with affected side up

41
COMPLICATIONS OF LAMINECTOMY AND DISCECTOMY

y Infection – Superficial wound infection , Deep disc space infection

y Thrombophlebitis / Deep vein thrombosis

y Pulmonary embolism

y Dural tears may result in Pseudo meningocoele, CSF leak,

Meningitis

y Postoperative cauda equina lesions

y Neurological damage or nerve root injury

y Urinary retention and urinary tract infection

LIMITED DISCECTOMY

y Only the extruded or sequestered portion of the disc is removed.

y The central or lateral portion of nucleus is not removed from the

disc space.

y One study only with a short term follow up

y Good results

y No recurrence

y Only 2% had persistent pain

42
LUMBAR MICROSURGICAL DISCECTOMY

y First reported by Williams in 1978

y Procedure of choice for herniated lumbar disc

y Decompression of the involved nerve root with minimum trauma to

the adjacent structures.

Advantages

◦ Decreased operative time

◦ Decreased morbidity

◦ Less loss of blood

◦ Shorter stay in the hospital

◦ Earlier return to work

y Drawbacks

◦ Inadequate exposure

◦ Incomplete decompression

◦ Costly equipment
y Contraindications

◦ Previously operated

◦ Spinal Canal Stenosis

43
ENDOSCOPIC DISCECTOMY

Endoscopic techniques have been developed with the advantage of

shortened hospital stay and faster return to activity. These techniques

generally are variations of the microdiscectomy technique using an

endoscope rather than the microscope and different types of retractors.

This remains another alternative technique. Each system is unique, and

the reader is referred to the technique guide of the various manufacturers

for details. The basic principles remain the same as with

microdiscectomy. Less-invasive tubular retractors also have been used in

a transmuscular fashion, allowing disc excision with less soft-tissue

damage because of the more precise exposure; however, better objective

clinical results have not been shown with this technique.

44
MATERIALS AND
METHODS
 MATERIALS AND METHODS

The study was conducted at Government Royapettah Hospital

Chennai and included 60patients with INTERVERTEBRAL DISC

PROLAPSE WITH LUMBAR RADICULOPATHY who fit the

inclusion criteria. It was a prospective study with patients followed up

with a written informed consent and as per proforma from all patients.

INCLUSION CRITERIA

Inclusion criteria were patients diagnosed of lumbar radiculopathy

by clinical examination, history taking and intervertebral disc prolapse on

the relevant nerve root evidenced by magnetic resonance imaging (MRI)

of lumbo sacral region.

Patients with radicular pain syndrome due to lumbar disc disease

1. Failed conservative line of management

2. Patients above the age of 18 and below 60 years

EXCLUSION CRITERIA

1. Generalised inflammatory disease

2. Previous use of anticoagulants

3. Uncontrolled diabetes

4. Previous adverse effects to lignocaine or contrast agents

5. Current suspected or diagnosed infection

45
 6. Poor general health

7. Difficulty of the patient in regular follow-up

8. Cutaneous disorders around the injection site

9. Previous injection at the same site within three months

10. Patients with Cauda equina syndrome.

RED FLAG SIGNS

1. Progressive neurological deficit

2. Bowel and bladder dysfunction

3. Thoracic pain

4. Saddle anaesthesia

5. Fever / unexplained weight loss

6. History of Carcinoma

7. Age above 65 years

DRUGS USED
• Drugs of choice
o Methylprednisolone 20 to 40 mg (1 ml)
o Triamcinolone suspension 20 or 40 mg (1 ml )
• Anaesthetic agents used
o 2.0% to 4.0% preservative-free lidocaine (0.5 to 2 ml )
o 0.5% to 0.75% bupivacaine (0.5 to 2 ml )
• Total of 2-3ml injected

46
RATIONALE

• STEROID – Via its anti inflammatory effects reduces their

inflammation around the nerve root.

• Local anaesthethics – blocks the nociceptive C fibres and reduces

the pain

METHOD OF STUDY

Study Design : Longitudinal prospective study

Study Period : June 2017 to October 2019 .

Study Centre : Department of Orthopaedics,

Govt. Royapettah Hospital

Chennai

Follow Up : POD-1, 1 month, 3 months , 6 months and 1 year .

PATIENT ASSESSMENT TOOLS

Patients evaluated with VAS and questionnaire (Oswestry Low

Back Pain Disability Questionnaire) related to the distribution and the

degree of their symptoms before and after the procedure. Pre

interventional VAS score was obtained from all patients and compared

with post-procedure scores. Questionnaire was issued to all patients and

profile of each patient documented. Pre interventional complete

47
Neurological examination was done. Dynamic radiographs were taken to

rule out any spinal instability.

OUTCOME

1. Visual analog score

2. Oswestry Disability Index (ODI) Score

3. Rolando morris score

4. Patient satisfactory score

VISUAL ANALOG SCORE

48
49
BLOOD INVESTIGATIONS

Hemoglobin level, total leucocyte count, differential leucocyte

count, platelet count, blood sugar, serum urea, creatinine, uric acid,

bleeding time and coagulation time.

RADIOLOGICAL INVESTIGATIONS

• X ray – AP & Lateral view , Dynamic radiographs (Flexion &

Extension views) were taken to rule out any spinal instability.

• MRI LS spine.

IN THEATRE

On arrival in the operating room after 6 hours of fasting for solid

food, routine monitors like noninvasive blood pressure,

electrocardiogram, and pulse oximetry were used. Peripheral

intravascular cannulation was established and Ringer's lactate solution

was started slowly. All patients received antibiotic ceftriaxone 1 g after

proper test dose and resuscitation equipments were checked.

PROCEDURE

€ Patient in prone position under fluoroscopic guidance the level of

disc herniation marked.

€ Place the C -arm in position first.

€ Identify the midpoint of the intervertebral space at the target level.

€ Adjust the lower endplate of the target vertebral body to be aligned

by moving the C -arm in a cephalocaudal direction

50
 INITIAL AP VIEW

In AP view, align the vertebral end plates, Spinous process in

midline, this is done by cephalad tilt of the image intensifier

51
 END PLATE ALIGNMENT

€ With the oblique of image intensifier, the pedicle of the

corresponding vertebra identified as the eye of the Scottish dog.

€ By sub pedicular approach, spinal nerve was approached.

€ After local infiltration of xylocaine, a 23 Gspinal needle was

utilized to reach the transforaminal space.

52
 € With the end-on view of the needle, 6’o clock position of the

pedicle is reached.

€ Ipsilateral tilt for scottish dog appearance.

To visualize the foramina, Next step is to tilt the image

intensifier obliquely by about 20 to 30 degrees. The pedicle of the

corresponding vertebra identified as the eye of the Scottish dog.

LATERAL VIEW

53
 Then with the image intensifier in AP view, radio-opaque dye is

injected. The dye used in our study was Iohexol. Equal volumes of dye

and distilled water were used.

Findings after dye injection

S shaped- along the nerve root pathway- Ideal – drug given.

Geographic pattern- suspect vascular injection- abandon the procedure.

Dye settles as linear shadow in lateral view – suspect intrathecal

injection- adjust the needle abandon the procedure.

If the dye was found to traverse the nerve root pathway, the

position of the needle was confirmed and drug injected. If the dye was

found to traverse a different path or geographic pattern the needle is

withdrawn and procedure is repeated with fine fluoroscopic

adjustments. Still if the dye is found to follow a different path,

accidental vascular injection of dye should be suspected and procedure

54
 was abbandonedd. After administrat
a tion of thhe drug, tthe dye will
w be

found diluted inn the subseequent fluo

oroscopic image.

D
Drug quivolume mixture of steroid and
administered is an eq

lignocaine (without any preserv

vative). Administr
A ration off local

anaesthhetic withh preservaative will cause floocculationn of the steroid.

s

The paatient is obbserved foor half an hour

h and shifted
s bacck to ward
d.

POST OP
P PROTO
OCOL

o day annd in bed mobilizatiion from 2nd day on

• Bedd rest for one nwards.

• Analgesics tiill 2nd day..

mbar strenngthening exercises from 7th day

• Lum d onwarrds.

• Weeight liftinng and spoorts after 2months.

2

• Som
me patiennts compllained off post-procedural inncrease in pain

attrributed to mass effeect of the drug being given inn foraminaal level

which settledd within 48 hours with

w analgeesics. Folloow up- VA
AS and
55
 ODI on POD-1 and on subsequent follow ups at 1 month, 3

months, 6 months and 1 year.

RISKS

• Direct injection into nerve root – Intense pain, damage of nerve

• Injection into blood vessel

• Dural puncture and Infections

• Bleeding – can compress the nerve root – short term worsening of

pain

• Radiation Exposure

DATA ANALYSIS

Pain (VAS Score) will be assessed on follow up. Patient clinical

improvement will be assessed based on serial follow up of VAS Score.

56
OBSERVATIONS

&

RESULTS
 OBSERVATION & RESULTS

AGE DISTRIBUTION

The following tables and charts show the age distribution of the

participants. Age of the patient ranges from 25 to 60 with the mean age of

38 years. Among 60 patients studied, mid age population from 30 to 50

(38 patients) years showed increased incidence.

AGE NO. OF CASES

20 – 30 8
30 – 40 18
40 – 50 20
50 – 60 14

Table 1 : Age Distribution

Age distribution of cases

25

20

15

10 No of cases

0
20-30 30-40 40-50 50-60

Figure 1 : Age Distribution

57
SEX DIS
STRIBUT
TION

Thee followinng tables and chartts show thhe sex disstribution of the

participannts. Out of 60 paatients, 26

6 were maales and 34 were female

patients inncluded inn our studyy.

SEX NO. OF CASES

C NO. O
OF CASES
S (%)

M
MALE 26 45 %

FE
EMALE 34 55 %

Table 2 : Gender Distribution

G
Gender distribu
ution off cases

Maale
Female

Figure 2 : Gendeer Distribu

ution

58
SIDE DIS
STRIBUT
TION

Thee followinng tables and chartts show thhe side distribution of the

o 60 patieents, 28 paatients hadd sciatica to right siide and

participannts. Out of

a 10 pattients had sciatica oon bilateral lower

22 patientts had on left side and

limbs.

SIDE NO. OF CASES

C

RIGHT 28

LEFT 22

BIILATERAL
L 10

Tablle 3 : Sidee distributtion

Sid
de distrribution
n

B/L

R Right

Left

Bilateraal
L

Figuree 3 : Side Distributtion

59
DISTRIBUTION – BASED ON DISC LEVEL

The following tables and charts show the distribution of cases

based on disc level. Out of 60 patients, 7 patients had L3-L4 disc

herniation, 20 patients had on L4- L5 level, 9 patients on L5 – S1 level.7

patients had disc herniation at L3- L4 & L4- L5 level, 17 patients on L4-

L5 & L5-S1 level.

DISC LEVEL NO OF CASES PERCENTAGE (%)

L3-L4 7 11
L4-L5 20 34
L5-S1 9 15
L3-L4, L4-L5 7 11
L4-L5, L5-S1 17 29

Table 4 : Categorical Distribution of Level Of Disc

Distribution of level of disc

L4-L5, L5-S1

L3-L4, L4-L5

L5-S1 No of cases

L4-L5

L3-L4

0 5 10 15 20 25

Figure 4 : Categorical Distribution of Level of Disc

60
DISTRIBUTION - BASED ON TYPE OF DISC-AXIAL SECTION

Based on type of disc herniation on axial section, 20 patients had

posterolateral, 27 had posterocentral and 13 had foraminal disc

herniations .

DISC TYPE NO OF CASES PERCENTAGE (%)

Postero lateral 20 33
Postero central 27 46
Foraminal 13 21

Table 5 : Categorical Distribution of disc herniation on axial section

Distribution of cases based on type of disc-

Axial section
30

25

20

15
No of cases

10

0
Postero lateral Postero central Foraminal

Figure 5 : Categorical Distribution of disc herniation on axial section

61
DISTRIBUTION - BASED ON TYPE OF DISC-SAGITTAL

SECTION

Out of 60 patients, 8 cases had localised disc herniation, 30 patients had

extrusion type and 22 patients had protrusion of disc herniation.

SAG NO OF CASES PERCENTAGE (%)

Localised 8 13
Extrusion 30 50
Protrusion 22 37
Sequestration 0 0

Table 6 : Categorical distribution of Disc Herniation on Sagittal Section

Distribution of cases based on type of disc-

Sagittal section
35

30

25

20

15 No of cases

10

0
Localised Extrusion Protrusion Sequestration

Figure 6 : Categorical distribution of Disc Herniation on Sagittal Section

62
 COMPARISON OF VAS SCORE PRE INJECTION & 1 YEAR FOLLOW-UP

VAS score which indicates better outcome with this treatment.

The 1 year follow up VAS Score was found to be significantly decreased

when compared to Pre injection.

1year Pre 1year

S. Pre Injection S.
Patient Name Follow Up Patient Name Injection Follow Up
NO Vas Score NO
Vas Score Vas Score Vas Score

1 ELIAZ 7 2 31 DEVENDER* 6 OPERATED

2 DEVAKI 8 2 32 PADMALAKSHMI 6 1

3 SINDHUJA 6 2 33 PRAKASH 7 2

4 KATHIRESAN* 8 6 34 ASAITHAMBI 7 2

5 VETRI CHELVAN 7 2 35 YASODA 6 2

6 NOORIN BEGUM* 8 7 36 KUMAR 6 2

7 SAROJA 7 2 37 BHAGAVATHY 8 2

8 JOHN 6 3 38 SANGEETHA 6 2

9 KARTHICK 7 2 39 BASKAR 7 2

10 GOWRI 7 2 40 PONNAPPAN* 8 7

11 JAYAVEL* 8 7 41 ANAND 6 2

12 SUMATHY 6 2 42 KAMATCHI* 7 7

13 SUDHA 6 2 43 MOHAMMED 6 2

63
14 VENKATESH 7 2 44 GEORGE 7 2

15 FATHIMA* 7 7 45 MATIYALAGI 6 2

16 MATHIAZHAGAN* 8 6 46 MURUGAYAH 6 2

17 ARUMUGAM* 7 OPERATED 47 REHANA* 6 OPERATED

18 CHINNAIYAN* 7 7 48 URMILA 6 2

19 SHANTHI 7 2 49 RAJENDRAN * 7 7

20 THILAGA 7 2 50 THAHIR 7 2

21 HEMALATHA* 6 7 51 JOHNPAUL 7 2

22 REHUMUNISHA 8 3 52 FARIDA 6 2

23 KALPANA* 7 6 53 KANAGA 7 2

24 MUTHUKUMAR 8 2 54 DHANABAGYAM 8 2

25 ZUBAIR AHMED 7 1 55 VARITHA 7 3

26 MANIKANDAN 6 2 56 PATTU LAKSHMI* 7 7

27 SORNAVADIVU 7 2 57 THULAKAMMAL 7 1

28 PARVATHY 8 2 58 VIMALA 8 2

29 SELVI 6 2 59 SWARNALATHA* 6 7

30 RANJITHAM* 8 7 60 SHANTHAMANI 7 2

* - Patients who failed at subsequent follow up.

64
 VAS SCORE

0
1
2
3
4
5
6
7
8
9
ELIAZ
DEVAKI
SINDHUJA
KATHIRESAN*
VETRI CHELVAN
NOORIN BEGUM*
SAROJA
JOHN
KARTHICK
GOWRI
JAYAVEL*
SUMATHY
SUDHA
VENKATESH
FATHIMA*
MATHIAZHAGAN*
ARUMUGAM
ARUMUGAM*
CHINNAIYAN*
SHANTHI
THILAGA
HEMALATHA*
REHUMUNISHA
KALPANA*
MUTHUKUMAR
ZUBAIR AHMED
MANIKANDAN
SORNAVADIVU

65
PARVATHY
SELVI
RANJITHAM*

Figure 7 : Compariing the Pre injjection and 1 Y

DEVENDER**
PADMALAKSHMI
PRAKASH
ASAITHAMBI
YASODA
KUMAR
BHAGAVATHY
Year follow VA

SANGEETHA
BASKAR
PONNAPPAN*
ANAND
KAMATCHI*
MOHAMMED
GEORGE
AS score of Pa

MATIYALAGI
MURUGAYAH
REHANA*
atients

URMILA
RAJENDRAN *
THAHIR
JOHNPAUL
PR

FARIDA
KANAGA
DHANABAGYAM
VARITHA
PATTU LAKSHMI*
THULAKAMMAL
S
S

VIMALA
SWARNALATHA*
SHANTHAMANI
1YEAR FOLLOW UP VAS SCORE,
RE INJECTION VAS SCORE,

2
7
ANALYSIS OF VAS SCORE

Among 60 patients, pre injection VAS score was 7.25. Immediate post

injection VAS score significantly decreased to 1.71. With further follow up at 1, 3, 6

and 12 months, there was a moderately increasing trend of VAS score with patients

reporting with recurrence of pain at subsequent follow up.

VAS SCORE
PRE INJECTION 7.25
Immediate post OP 1.7
1st month 2.1
3rd month 2.3
6th month 2.3
12th month 2.5

Table 8 : VAS score at serial follow up

VAS SCORE
8
6
4
2
0 VAS SCORE

Figure 8 : VAS score at serial follow up

66
 RESULTS

During the study period, 60 patients underwent SNRB and formed

the study cohort. All of them underwent SNRB by trained surgeons as

described previously.

Out of 60 patients, 26 were males and 36 were females. Age of

the patient ranges from 25 to 60 with a mean age of 42 age has no

significance related to the outcome. In this study, 28 patients had

sciatica on right side and 22 had on left side and 10 had on bilateral side

. In this study, the level of disc herniation doesn’t have any significance.

Post operative rehabilitation was started according to the

protocol. All the patients were available for periodic follow-up till 1

year at regular intervals the VAS Score was analysed and documented

to assess the functional outcome. Functional outcome was based on

patient’s pain scoring system by Visual analog score. Visual analog

score is 10 point score measured on a longitudinal scale. In our study,

pre injection mean VAS score was 7.25 and post operative VAS score

was 2.5(P= 0.004). It indicates that transforaminal block improves the

outcome of patients with lumbar radiculopathy.

67
 During the follow-up, 43 patients had good pain relief maintained

till 1 year (43/60,71.8% efficacy). 17 patients had recurrence of pain in

subsequent serial follow up till 1 year. Out of 17 patients, 3 patients

underwent surgery at a mean of 5 weeks after the failed SNRB. In none

of the failed patients second injection was tried.

Patients with complications such as dizziness and temporary

muscular weakness were moved to the recovery room for observation

and all symptoms were absent at discharge. No correlations were found

between the success rate and several investigated factors, such as

injection method, age, gender and prevalence period.

Other factors including age (P= 0.41 ), sex (P=0.31), side of

pain(P=0.19), level of lesion (L3-4,L4-5 and L5 -S1) (P=0.54) and other

MRI findings (disc type and position, level of degeneration) (P=0.62 )

were not predictive .

68
CASE ILLUSTRATIONS
 ILLUSTRATIONS
CASE 1
NAME, AGE :DEVAKI 60/F
DIAGNOSIS :IVDP L4-L5, LEFT SCIATICA

PRE OP XRAY

PRE OP MRI

69
 Scottish Dog Appearance Spinal Needle At L5 Pedicle

LATERAL VIEW DYE INJECTED DYE DILUTION

PRE OP 1 YEAR FOLLOW UP

VISUAL
ANALOG
SCORE

70
CASE 2
NAME, AGE : SHANTHI 42 / F
DIAGNOSIS : IVDP L4-L5 , L5-S1

PRE OP XRAY

PRE OP MRI

71
 L 5 ROO
OT BLOC
CK

INTR
RA OP
C ARM
A
S1 ROO
OT BLOC
CK

PRE OP
P 1 YEAR FOLLOW
W UP

VISU
UAL
ANALLOG
SCO
ORE

72
CASE 3

NAME, AGE : PRAKASH 40 / M

DIAGNOSIS : IVDP L4-L5,L5-S1

PRE OP XRAY

PRE OP MRI

73
INTRA OP
C ARM

PRE OP 1 YEAR FOLLOW UP

VISUAL
ANALOG
SCORE

74
CASE
E4

NAME
E, AGE : REH
HUMUNIISHA 31// F

DIAG
GNOSIS : IVD
DP L4-L5,, L5-S1

PRE OP
O XRAY
Y

PRE OP
O MRI

75
 L5 RIGHT

INTRA
A OP
C ARM
M

PRE OP 1 YEA
AR FOLLO
OW UP

AL
VISUA
ANALLOG
SCORRE

76
CASE
E5

NAME
E, AGE : AR
RUMUGAM
M 57 / M

DIAG
GNOSIS : IVD
DP L4-L55, L5-S1

PRE OP
O XRAY
Y

PRE OP
O MRI

77
 L5 NER
RVE ROO
OT

S1 NER
RVE ROO
OT

INTRA
A OP
C ARM
M

PRE OP
O IM
MMEDIA
ATE POST
T INJECTION

VISUA
AL
ANALLOG
SCORRE

OP
PERATE
ED AT 1 MONTH

78
CASE
E6

NAME
E, AGE : REH
HANA 533/F

DIAG
GNOSIS : IVD
DP L3-L4,,L4-L5
PROC
CEDURE : L4 ROOT BL
LOCK LE
EFT

PRE OP
O XRAY

PRE OP
O MRI

79
INTRA
OP
C ARM

PRE OP IMMEDIATE POST INJECTION

VISUAL
ANALOG
SCORE

OPERATED AT 1 MONTH

80
DISCUSSION
 DISCUSSION

Selective steroidal nerve root block is a standard initial care of

intervention in patients with recalcitrant radicular pain

followingLDH.9Lumbosciatic pain caused by intervertebral disc

herniation is a common and important medical problem with enormous

socioeconomic impact. Absolute indications for acute surgery of

prolapsed intervertebral discs are symptoms of a cauda equina

syndrome, the presence of acute, severe motor deficit and intractable

pain. No significant improvement after 2 months of conservative

therapy is a relative indication for surgery. The prevalence of sciatic

symptoms reported in the literature varies considerably ranging from

1.6% in the general population to 43% in a selected working population.

Although the prognosis is good in most patients a substantial proportion

(up to 30%) continues to have pain for 1 year or longer. In

approximately 90% of the cases, sciatica is caused by a herniated disc

involving nerve root compression.10 However, lumbar canal stenosis or

foraminal stenosis and (less often) tumours or cysts are other possible

causes

The most important symptom of sciatica is lumbosacral radicular

leg pain that follows a dermatomal pattern radiating below the knee and

81
into the foot and toes. The pain worsens with coughing, patients may

report sensory symptoms, limited forward flexion of the lumbar spine,

gait deformity and unilateral spasm of the paraspinal muscles. However,

most patients present with a less clear clinical picture. In acute sciatica,

diagnostic imaging may only be indicated if there are indications of

underlying pathology (e.g. infections, malignancies) other than disc

herniation. In patients with persistent and severe symptoms who fail to

improve following 6–8 weeks of non-surgical treatment, imaging might

be useful to identify the presence or absence of a herniated disc with

nerve root compression.11

In all other cases, conservative management seems to have

identical long-term results compared with surgery. On the basis of

reviewed prospective randomized trials, in the acute phase of sciatica,

only bed rest for 2 to 7 days and adequate pain medication have been

proven effective. As one method to shorten recovery, epidural

corticosteroid injections in radicular pain therapy are used frequently,

although results regarding their efficacy vary. 12,13

The efficacy of epidural corticosteroid injection in conservative

management of lumbosciatic pain caused by nucleus pulposus prolapse

remains a matter of controversy. Experimental studies suggest that the

anti-inflammatory reaction and decreased local edema occuring after

82
corticosteroid injections are a consequence of the inhibition of multiple

inflammatory mediators, including phospholipase. Phospholipase A2

has been found to be produced in higher levels after disc herniation.

Inhibition of the synthesis of these inflammatory mediators by

corticosteroids ultimately leads to interruption of pain generation.

Epidural corticosteroid injection has been attempted as a potential

therapy in numerous spinal diagnosis, in low back pain with and

without radicular symptoms, post nucleotomy syndrome, spinal stenosis

and in elderly patients with back pain often without having excluded

degenerative changes. Efficacy of corticosteroids in these cases is of

debatable value, especially in cases without sciatica and radicular

components. For instance, it should be questioned whether lumbosciatic

pain provoked by osseous and degenerative changes could be

influenced positively by the physiologic effect of corticosteroids.

Epidural steroid injections for lumbar radiculopathy had clinical

effects, and the transforaminal approach, when compared to others, was

effective in improving symptoms with smaller amount of agents,

because the agents could easily reach the targeted nerve root, dorsal root

ganglion and the anterior of epidural space. However, the

transforaminal approach may induce severe complications during the

procedure, including steroid injection into vessels, vessel convulsion by

83
direct damage by the needle and ischemic spinal nerve damage by

embolism.14,15,16 To date, 12 published cases have reported severe

neurological damage by lumbar, dorsal and transforaminal steroid

epidural injection. Glaser and Falco reported the first case of lower limb

paralysis by ischemic spinal damage after lumbar, dorsal and

intervertebral foramen steroid epidural injection, even when the needle

was located in the safe triangle by the subpedicular approach.

As for the lumbar spinal nerve, there is a triangular area in which

the nerve leaves the intervertebral foramen obliquely to form the

hypotenuse, the connected line to the lower part of the pedicle is the

bottom side, and the line forming a right angle against the exterior of

the pedicle is the vertical plate. This area is called "the safe triangle,"

because the space mainly contains only the spinal nerve and

vessel18. However, the structure of the safe triangle excludes the

anatomical structure of artery. The most dangerous radiculo medullary

artery in lumbar transforaminal injection is the AKA artery. In 80% of

healthy people, when penetrating the spinal canal, the artery enters the

intervertebral foramen between left T9 (9th thoracic vertebra) and L1

(1st lumbar vertebra). However, care should be taken because in about

20% of cases it enters the intervertebral foramen between L2 and L4.

The main trunk of the AKA enters the medial spinal canal through

84
either the mid or the rostral portion of the foramen. There it passes

through the proximal portion of the dorsal root ganglion and the ventral

root complex19 Therefore, the subpedicular approach is likely to damage

blood vessels such as the AKA or to trigger complications, such as

spinal cord infarction resulting from the intravascular injection of

particulate steroids, because the injection needle is placed in the anterior

superolateral aspect of the intervertebral foramen.

In the subpedicular approach, the needle is located in the anterior

of the intervertebral foramen crossing the nerve root. Thus, it may prick

the spinal nerve root during injection because it is difficult for the

needle to be located in the anterior epidural space through the safe

triangle in severe spinal stenosis, epidural fibrosis, and sunken

degenerative intervertebral disc region. Meanwhile, in the Kambin's

triangle approach, the needle is located in the inferior-posterior on

lateral view, reducing the risk of pricking the spinal nerve root.20Being a

pain-relieving interventional procedure, it also falls in the hands of

different medical care specialists, including spine surgeons, radiologists,

anesthesiologists and pain physicians and thus the inclusion criteria and

evaluation of patients varies widely in different studies.

Lee et al21 studied the MRI-based outcome predictors of lumbar

transforaminal steroid injections in patients with LDH (n ¼ 149) and

85
showed that LDH in the foraminal-extraforaminal zone had

significantly better outcomes with nerve blocks while other factors such

asT2-high signal, relation to nerve root, corner change, Modic change,

disc height loss, grade of disc degeneration, and osteophyte were not

statistically significant. It is emphasized that MRI Findings does not

correlate with severity of size of herniation, hence decision should be

made on clinical grounds and psychological factors should be given

more importance than imaging . It is also stated that MRI not indicated

for acute low back ache with/without radiculopathy without the

presence of red flag signs. Due importance to be given to position of

the patient while taking MRI as it can alter the disc dimensions.21,22

In 2017, Rishi M kanna et al, During the follow-up, 69 patients had

good pain relief till 1 year (69out of 91patients ,75.8% efficacy).The

radiculogram produced by injecting the dye around the nerve root could

be an indicator to evaluate the efficacy of SNRB since it demonstrates

the pattern of flow of the drug around the inflamed nerve root.

Pfirrmannet al25 studied the flow of contrast material in 36 patients and

classified as type 1 (tubular appearance intraepineural), type 2 (nerve

root visible as filling defect-extra epineural), or type 3 (nerve root not

visible-paraneural) based on a comparative evaluation incadavers. The

authors noted that SNRB is effective in sciatica, but type 1 injections

86
(intraepineural) were more painful than type 2 injections.8 In a similar

study by Lee et al in 56 patients,76.8% success was achieved at the end

of 2 weeks with SNRB and multiple regression analysis showed that the

only factor significantly associated with better outcome was the

extraepineural type of injection. Exact duration of relief was not

predictable, but various studies have shown excellent results for upto a

period of 5 years in 70-80% of the cases. To our knowledge this study ,

perhaps consisting of 60 patients having lumbar radiculopathy with

intervertebral disc prolapse participating with follow up of 1 year . The

evaluation was carried out by the degree of the pain and comparing the

pre op and post op VAS score by subsequent outpatient visits at 1, 3, 6,

12 months (final follow up ). The degree of pain was assessed using

visual analogue score. Pre injection average pain (VAS) was 7.25

(range 6 – 9) after selective transforaminal block the average pain score

decreased from 7.25 to 2.5 at one year follow up. Most no of patients

significantly improved with a single dose transforaminal block

injection. 72 % of the patients had complete pain relief upto a follow

up period of one year.

87
 The significant maximal benefit was reached at immediate post

injection status. Selective transforaminal block injection is an easy

procedure, safe (no reactions), cheap for both patient & institution

devoid of any biohazard complications, minimally traumatic, avoids

regular usage of NSAIDS, early recovery, no complications, effective &

reduced recurrence rate, provides pain free state and improving

functional status.

88
CONCLUSION
 CONCLUSION

The immediate response to transforaminal epidural steroid

injection was satisfactory and has a considerable pain free life style over

a short term of 1 year and its outcome for a long term pain relief has to

be further evaluated in coming days .

We conclude that Transforaminal epidural steroid injection is a

reasonably safe procedure to provide short-term pain relief for lumbar

radiculopathy in intervertebral disc prolapse .

89
BIBLIOGRAPHY
 BIBLIOGRAPHY

1. Helio¨vaara M, Impivaara O, Sievers K, et al. Lumbar disc syndrome

in Finland. J Epidemiol Community Health. 1987;41: 251-258

2. Solberg TK, Nygaard ØP, Sjaavik K, Hofoss D, Ingebrigtsen T. The

risk of “getting worse” after lumbar microdiscectomy. Eur Spine J.

2005;14:49-54. doi:10.1007/s00586-004-0721-5

3. Cyteval C, Fescquet N, Thomas E, Decoux E, Blotman F, Taourel P.

Predictive factors of efficacy of periradicular corticosteroid

injections for lumbar radiculopathy. AJNR Am J Neuroradiol.

2006;27:978-982.

4. McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for

back and leg pain: mechanisms of action and efficacy. Spine J.

2005;5:191-201.

5. Park, J. W., Nam, H. S., Cho, S. K., Jung, H. J., Lee, B. J., & Park,

Y. (2011). Kambin's triangle approach of lumbar transforaminal

epidural injection with spinal stenosis. Annals of rehabilitation

medicine, 35(6), 833.

6. Jacobs WCH, van Tulder M, Arts M, et al. Surgery versus

conservative management of sciatica due to a lumbar herniated disc:

a systematic review. Eur Spine J. 2011;20:513-522.

doi:10.1007/s00586-010-1603-7
7. Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C,

Goette K. The effect of nerve-root injections on the need for

operative treatment of lumbar radicular pain. A prospective,

randomized, controlled, double-blind study. J Bone Joint Surg

Am. 2000;82:1589–1593.

8. Pfirrmann CW, Oberholzer PA, Zanetti M, et al. Selective

nerverootblocks for the treatment of sciatica: evaluation of

injectionsite and effectiveness—a study with patients and

cadavers.Radiology. 2001;221:704-711.

9. Datta, S., Pai, U., &Gajraj, N. M. (2004). Selective Nerve Root

Block-Is the Position of the Needle Transforaminal or

Paraforaminal? Call for a Need to Reevaluate the Terminology/Reply

to Dr.Datta. Regional anesthesia and pain medicine, 29(6), 616.

10. Lee JW, Kim SH, Lee IS, et al. Therapeutic effect and outcome

predictors of sciatica treated using transforaminal epidural steroid

injection. AJR Am J Roentgenol. 2006;187:1427-1431. doi:10.

2214/AJR.05.1727

11. Cooper G, Lutz GE, Boachie-Adjei O, Lin J. Effectiveness of

transforaminal epidural steroid injections in patients with

degenerative lumbar scoliotic stenosis and radiculopathy. Pain

Physician.
12. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural

steroid injections in lumbosacral radiculopathy: a prospective

randomized study. Spine. 2002;27:11–16.

13. Boswell MV, Hansen HC, Trescot AM, Hirsch JA. Epidural steroids

in the management of chronic spinal pain and radiculopathy. Pain

Physician. 2003;6:319–.

14. Kanna, R. M., Shetty, A. P., &Rajasekaran, S. (2018). Predictors of

successful outcomes of selective nerve root blocks for acute lumbar

disc herniation. Global Spine Journal, 2192568218800050.

15. McCormick Z, Cushman D, Casey E, Garvan C, Kennedy DJ,

Plastaras C. Factors associated with pain reduction after

transforaminal epidural steroid injection for lumbosacral radicular

pain. Arch Phys Med Rehabil. 2014;95:2350-2356.

doi:10.1016/j.apmr. 2014.07.404.

16. Slipman CW, Chow DW. Therapeutic spinal corticosteroid injections

for the management of radiculopathies. Phys Med RehabilClin N

Am. 2002;13:697–711.

17. Rydevik B, Brown MD, Lundborg G. Pathoanatomy and

pathophysiology of nerve root compression. Spine. 1984;9:7–15.

18. Glaser SE, Shah RV. Root cause analysis of paraplegia following

transforaminal epidural steroid injections: the 'unsafe' triangle. Pain

Physician. 2010;13:237–244.
19. Alleyne CH, Jr, Cawley CM, Shengelaia GG, Barrow DL.

Microsurgical anatomy of the artery of Adamkiewicz and its

segmental artery. J Neurosurg. 1998;89:791–795.

20. Kambin P, Sampson S. Posterolateral percutaneous suction-excision

of herniated lumbar intervertebral discs. Report of interim

results. ClinOrthopRelat Res. 1986;207:37–43

21. Crall TS, Gilula LA, Kim YJ, Cho Y, Pilgram T, Riew KD. The

diagnostic effect of various needle tip positions in selective lumbar

nerve blocks: an analysis of 1202 injections. Spine. 2006;31:920–

922.

22. Tajima T, Furukawa K, Kuramochi E. Selective lumbosacral

radiculography and block. Spine (Phila Pa 1976).

23. Seidler A, Bolm-Audorff U, Siol T, et al. Occupational risk factors or

symptomatic lumbar disc herniation; a case-control study Occup

Environ Med. 2003;60:821-830.

24. Seidler A, Bolm-Audorff U, Siol T, et al. Occupational risk

factorsfor symptomatic lumbar disc herniation; a case-control study.

Occup Environ Med. 2003;60:821-830.

25. McCarron, RF, Wimpee, MW, Hudkins, PG, Laros, GS1987.The

inflammatory effect of nucleus pulposus: a possible element in the

pathogenesis of low back pain.Spine12760764

26. Yeom JS, Lee JW, Park KW, et al. Value of diagnostic lumbar

selective nerve root block: a prospective controlled study. AJNR Am

J Neuroradiol. 2008;29:1017-1023. doi:10.3174/ajnr.A0955.

27. . Goupille P, Jayson MI, Valat JP, Freemont AJ. Matrix

metalloproteinases: the clue to intervertebral disc degeneration.

Spine (Phila Pa 1976). 1998;23:1612-1626

 CONSENT FORM

FOR OPERATION / ANAESTHESIA

I ( ) in my full senses hereby give my full

consent for or any other procedure deemed fit which is a therapeutic

injection to be performed on me. The nature, risks and complications

involved in the procedure have been explained to me in my own language

and to my satisfaction. For academic and scientific purpose the

operation/procedure may be photographed or televised.

Date:
Signature / Thumb Impression

Name of Patient / Guardian

Designation Guardian
Relationship
Full address
 PATIENT CONSENT FORM
Study detail : “FUNCTIONAL OUTCOME OF SELECTIVE
TRANSFORAMINAL NERVE ROOT BLOCK FOR LUMBAR
RADICULOPATHY IN INTERVERTEBRAL DISC PROLAPSE”

Study Centre : GOVT ROYAPETTAH HOSPITAL, CHENNAI

Patients Name :

Patients Age :

Identification Number :

Patient may check (√) these boxes

1. I confirm that I have understood the purpose of procedure for the above study. I had
the opportunity to ask question and all my questions and doubts have been answered
to my complete satisfaction.
2. I understand that my participation in the study is voluntary and that I am free to
withdraw at any time without giving reason, without my legal rights being affected.
3. I understand that sponsor of the clinical study, others working on the sponsor’s
behalf, the ethical committee and the regulatory authorities will not need my
permission to look at my health records, both in respect of current study and any
further research that may be conducted in relation to it, even if I withdraw from the
study I agree to this access. However, I understand that my identity will not be
revealed in any information released to third parties or published, unless as required
under the law. I agree not to restrict the use of any data or results that arise from this
study.
4. I hereby make known that I have fully understood the use of above surgical
procedure, the possible complications arising out of its use and the same was clearly
explained to me and also understand treatment of polytrauma with fractures and this
study is done to know the usefulness of the same in management of fractures in
polytrauma patients.
5. I agree to take part in the above study and to comply with the instructions given
during the study and faithfully cooperate with the study team and to immediately
inform the study staff if I suffer from any deterioration in my health or well-being or
any unexpected or unusual symptoms.
6. I hereby consent to participate in this study.
7. I hereby give permission to undergo complete clinical examination and diagnostic
tests including hematological, biochemical, radiological tests.

Signature/thumb impression:

Patients Name and Address: Place date

Signature of investigator :

Study investigator’s Name : Place date

 ேநாயாளிஒப் தல் ப வம்

ஆராய் ச ் ன் வரம் :

ஆராய் ச ் ைமயம் :

ேநாயாளி ன்ெபயர ்:

ேநாயாளி ன்வய :

ப எண்:

ேநாயாளி ழ் கண்டவற் ள் கட்டங் கைள (D)ெசய் ய ம்

1. ேமற் ப் ட் ள் ளஆராய் ச ் ன்ேநாக்கத்ைத ம் பயைன ம்

வ மாக ரிந் ெகாண்ேடன்.
ேம ம் என அைனத் சந்ேதகங் கைள ம் ேகட் அதற் கான ளக்கங்
கைள ம் ெதளி ப த் க்ெகாண்ேடன்.

2. ேம ம் இந்தஆராய் ச ் க் என ெசாந்த ப்பத் ன்ேபரில் பங் ேகற்

ேறன்என் ம் ,
ேம ம் எந்தேநரத் ம் எவ் த ன்ன ப் ன் இந்தஆராய் ச ்
ந் லக ைமயானஉரிைமஉள் ளைத ம் ,
இதற் எவ் தசட்ட ைணப் ம் இல் ைலஎன்பைத ம் அ ேவன்.

3. ஆராய் ச ் யாளேரா, ஆராய் ச ் உத யாளேரா,

ஆராய் ச ் உபயத்தாேரா, ஆராய் ச ் ேபரா ரியேரா,
ஒ ங் ெந ெசயற் உ ப் னர ்கேளாஎப்ேபா ேவண் மானா
ம் என அ ம ன் என உள் ேநாயாளிப கைளஇந்தஆராய் ச ்
க்காகேவாஅல் ல எ ர ்கால றஆராய் ச ் க க்காகேவாபயன்ப த்
க்ெகாள் ளலாம் என் ம் ,
ேம ம் இந்தநிபந்தைனநான்இவ் வாரய் ச ் ந் ல னா ம் த
ம் என் ம் ஒப் க்ெகாள் ேறன்.
ஆ ம் என அைடயாளம் சம் பந்தப்பட்டஎந்தப க ம்
(சட்ட ர ்வமானேதைவகள் த ர)
ெவளி டப்படமாட்டா என்றஉ ெமா ன்ெபயரில் இந்தஆராய்
ச் ந் ைடக்கப்ெப ம் கைளெவளி டம ப் ெத
க்கமாட்ேடன்என் உ யளிக் ன்ேறன்.

4. இந்தஆராய் ச ் க் நான் மன டன்சம் ம க் ன்ேறன்என் ம் ேம

ம் ஆராய் ச ் க் னர ்எனக் அளிக் ம் அ ைரகைளதவறா
ன்பற் ேவன்என் ம் இந்தஆராய் ச ் காலம் வ ம் என உடல் நி
ைல ல் ஏேத ம் மாற் றேமாஅல் ல எ ர ்பாராதபாதகமான ைள
ேவாஎற் ப மா ன்உடன யாகஆராய் ச ் னைரஅ ேவன்எ
ன் ம் உ யளிக் ன்ேறன்.
5. இந்தஆராய் ச ் க் த்ேதைவப்ப ம் அைனத் ம த் வப்பரிேசாத
ைனக க் ம் ஒத் ைழப் த ேவன்என் உ யளிக் ன்ேறன்.

6. இந்தஆராய் ச ் க் யா ைடயவற் த்த ன் என ெசாந்த ப்

பத் ன்ேபரி ம் யஅ ட ம் மன ட ம் சம் மத் க் ன்ேறன்
என் இதன் லம் ஒப் க்ெகாள் ேறன்.

ேநாயாளி ன்ைகெயாப்பம் / ெப ரல் ைகேரைக

ஆராய் ச ் யாளரின்ைகெயாப்பம்

இடம் :

ேத :
 PROFORMA

AN ANALYSIS OF FUNCTIONAL OUTCOME OF SELECTIVE

TRANSFORAMINAL NERVE ROOT BLOCK FOR LUMBAR
RADICULOPATHY IN INTERVERTEBRAL DISC PROLAPSE

™ NAME :

™ AGE / SEX :

OCCUPATION :

™ OP NO :

™ ADDRESS :

™ MOBILE NO :

™ ANY ILLNESS / INJURY :

™ DIAGNOSIS :

™ PROCEDURE :

™ DATE OF PROCEDURE :

BEFORE
1 st 12
INJECTIO 1 month 3 month 6Month
Day Month
N

VAS
SCORE

™ POST PROCEDURE :
PERIOD
 ABBREVIATION

SNRB - Selective Nerve Root Block

AKA - Adamkiewicz Artery

VAS - Visual Analog Score

TNF - Tumour Necrosis Factor

SLRT - Straight Leg Raising Test

POD - Post Operative Day

IVDP - Intervertrebral Disc Prolapse

LDH - Lumbar Disc Herniation

 ZONE (Axial Section)
SIDE OF RADIATING

TRANSFORAMINAL

TYPE (SAGITTAL
BLOCK LEVEL
DIAGNOSIS

SELECTIVE
Age / Sex

SECTION)
NAME
VISUAL ANALOG SCORE

IP NO

PAIN
S.No

DOS

MRI

MRI

IMMEDIATE POST OP

3 MONTHS

6 MONTHS
1 MONTH
PRE OP

1 YEAR
1 31.10.2017 ELIAZ 53/M 1098 IVDP L4 L5 RIGHT L5 NERVE ROOT PL LOCALIZED 7 1 2 2 2 2
2 11.11.2017 DEVAKI 60/F 820 IVDP L4- L5 LEFT L5 NERVE ROOT PC EXTRUSION 8 2 2 2 2 2
3 14.11.2017 SINDHUJA 33/F 831 IVDP L3L4 LEFT L4 NERVE ROOT PL PROTRUSION 6 3 3 3 3 2
4 14.11.2017 KATHIRESAN 27/M 931 IVDP L3L4 RIGHT L4 NERVE ROOT PC EXTRUSION 8 3 4 6
5 16.11.2017 VETRI CHELVAN 51 /M 842 IVDP L4L5 RIGHT L5 NERVE ROOT PC PROTRUSION 7 3 3 2 2 2
6 17.11.2017 NOORIN BEGUM 38/F 821 IVDP L4L5 RIGHT L5 NERVE ROOT PC EXTRUSION 8 3 4 4 4 7
7 17.11.2017 SAROJA 46/F 1023 IVDP L4L5 RIGHT L5 NERVE ROOT PC EXTRUSION 7 2 2 2 2 2
8 18.11.2017 JOHN 54/M 868 IVDP L5S1 LEFT S1 NERVE ROOT PL EXTRUSION 6 2 2 3 3 3
9 22.11.2017 KARTHICK 32/M 912 IVDP L3L4 RIGHT L4 NERVE ROOT Foraminal PROTRUSION 7 2 3 3 2 2
10 30.11.2017 GOWRI 33/F 875 IVDP L5S1 RIGHT S1 NERVE ROOT PC LOCALIZED 7 1 1 1 2 2
11 1.12.2017 JAYAVEL 47/M 865 IVDP L5S1 LEFT S1 NERVE ROOT PL EXTRUSION 8 4 5 5 5 7
12 02.12.2017 SUMATHY 23/F 821 IVDP L3L4 RIGHT L4 NERVE ROOT PL EXTRUSION 6 2 2 2 2 2
13 03.12.2017 SUDHA 45/F 884 IVDP L4L5 RIGHT L5 NERVE ROOT PL PROTRUSION 6 1 1 1 1 2
14 19.12.2017 VENKATESH 57/M 929 4-L5, L5-S1 RIGHT L5 NERVE ROOT PL EXTRUSION 7 3 3 2 2 2
15 02.01.2018 FATHIMA 44/F 901 IVDP L3L4 L4L5 LEFT L4, L5 NERVE ROOT Foraminal EXTRUSION 7 3 3 7
16 02.01.2018 MATHIAZHAGAN 40/M 113 IVDP L4L5 L5S1 B/L B/L L5 , S1 NERVE PL PROTRUSION 8 3 3 3 6
IVDP L4L5
17 06.01.2018 ARUMUGAM 57 /M 591 L5S1 RIGHT L5 , S1 NERVE ROOT PC EXTRUSION 7 2 6 OPE RAT ED
18 07.01.2018 CHINNAIYAN 34/M 921 IVDP L4L5 RIGHT L5 NERVE ROOT Foraminal PROTRUSION 7 3 3 3 6
19 09.01.2018 SHANTHI 42/F 815 IVDP L4L5 L5S1 LEFT L5 S1 NERVE ROOT Foraminal PROTRUSION 7 2 2 2 2 2
20 16.01.2018 THILAGA 37/F 902 IVDP L4L5 L5S1 LEFT L5 S1 NERVE ROOT PC PROTRUSION 7 2 3 2 2 2
21 22.01.2018 HEMALATHA 50/F 912 IVDP L3L4 L4L5 B/L B/L L5S1 NERVE ROOT PL EXTRUSION 6 2 3 3 4 7
22 27.01.2018 REHUMUNISHA 31/F 2572 IVDP L4L5 L5S1 RIGHT L5 NERVE ROOT FORAMINAL LOCALIZED 8 2 2 3 3 3
23 27.01.2018 KALPANA 23/F 2852 IVDP L3L4 L4L5 RIGHT L5 S1 NERVE ROOT FORAMINAL EXTRUSION 7 3 3 6
24 05.02.2018 MUTHUKUMAR 50/M 3337 IVDP L4L5 L5S1 B/L L5 S1 NERVE ROOT PL PROTRUSION 8 3 3 2 2 2
25 07.02.2018 ZUBAIR AHMED 41/M 3098 IVDP L3L4 L4L5 LEFT L4 L5 NERVE ROOT FORAMINAL LOCALIZED 7 2 2 2 2 1
26 09.02.2018 MANIKANDAN 46/M 3012 IVDP L3L4 L4L5 LEFT L4 L5 NERVE ROOT PL PROTRUSION 6 2 3 3 2 2
27 11.02.2018 SORNAVADIVU 31/F 2980 IVDP L5S1 RIGHT S1 NERVE ROOT PC PROTRUSION 7 2 2 2 2 2
28 22.02.2018 PARVATHY 49/F 3012 IVDP L5S1 LEFT S1 NERVE ROOT FORAMINAL LOCALIZED 8 3 2 2 2 2
29 10.03.2018 SELVI 43/F 3522 IVDP L4L5 L5S1 LEFT L5 S1 NERVE ROOT PC PROTRUSION 6 3 3 2 2 2
30 13.03.2018 RANJITHAM 51/F 3876 IVDP L4L5 RIGHT L5 NERVE ROOT FORAMINAL EXTRUSION 8 3 4 6
31 15.03.2018 DEVENDER 27/M 9524 IVDP L4L5 LEFT L5 NERVE ROOT PC EXTRUSION 6 2 6 OPE RAT ED
32 23.03.2018 PADMALAKSHMI 35/F 4076 IVDP L4L5 RIGHT L4 NERVE ROOT PC PROTRUSION 6 2 2 2 2 1
33 17.04.2018 PRAKASH 40/M 10430 IVDP L4L5 L5S1 LEFT L5 NERVE ROOT PC EXTRUSION 7 3 3 3 3 2
34 21.04.2018 ASAITHAMBI 38/M 10827 IVDP L4L5 L5S1 RIGHT L5 NERVE ROOT FORAMINAL EXTRUSION 7 3 3 3 2 2
35 23.04.2018 YASODA 38/F 10298 IVDP L4L5 L5S1 LEFT L5S1 NERVE ROOT FORAMINAL EXTRUSION 6 2 2 2 2 2
36 23.04.2018 KUMAR 39/M 10654 IVDP L4L5 LEFT L5 NERVE ROOT PC PROTRUSION 6 1 2 2 2 2
37 27.04.2018 BHAGAVATHY 33/M 10432 IVDP L4L5 RIGHT L5 NERVE ROOT PL EXTRUSION 8 2 2 2 2 2
38 29.04.2018 SANGEETHA 35/F 11758 IVDP L4L5 LEFT L5 NERVE ROOT PC PROTRUSION 6 3 3 2 2 2
39 14.05.2018 BASKAR 48/M 12870 IVDP L4L5 RIGHT L5 NERVE ROOT FORAMINAL EXTRUSION 7 2 2 2 2 2
40 16.05.2018 PONNAPPAN 44/M 10234 IVDP L5S1 B/L L5 S1 NERVE ROOT PC PROTRUSION 8 3 3 3 7
41 22.05.2018 ANAND 29/M 10253 IVDP L3L4 RIGHT L4 NERVE ROOT PL LOCALIZED 6 2 3 3 3 2
IVDP L4-L5 L5-
42 28.05.2018 KAMATCHI 55/F 14214 S1 LEFT L5 S1 NERVE ROOT FORAMINAL PROTRUSION 7 3 2 3 3 7
43 01.06.2018 MOHAMMED 39/M 10253 IVDP L5S1 RIGHT S1 NERVE ROOT PL PROTRUSION 6 3 3 3 2 2
44 17.06.2018 GEORGE 50/M 10987 IVDP L5S1 LEFT S1 NERVE ROOT PC EXTRUSION 7 2 2 2 2 2
IVDP L4 L5 L5
45 6/7/2018 MATIYALAGI 30/F 18369 S1 RIGHT L5, S1 NERVE ROOT PC EXTRUSION 6 3 3 3 3 2
46 23/7/2018 MURUGAYAH 56/M 19943 IVDP L4L5 B/L B/L L5 NERVE ROOT PL PROTRUSION 6 2 2 2 2 2
IVDP L3L4 ,
47 25.07.2018 REHANA 53/F 10234 L4L5 LEFT L4 NERVE ROOT PC EXTRUSION 6 2 6 OPE RAT ED
48 27.07.2018 URMILA 28/F 12563 IVDP L3L4 L4L5 B/L B/L L4L5 NERVE ROOT PC LOCALIZED 6 2 2 2 2 2
49 27/7/2018 RAJENDRAN 52/M 20740 IVDP L4L5 LEFT L5 NERVE ROOT PC EXTRUSION 7 3 3 3 6
50 08.08.2018 THAHIR 47/M 20187 IVDP L4L5 L5S1 B/L B/L L5S1 NERVE ROOT PL EXTRUSION 7 3 2 2 2 2
51 10/8/2018 JOHNPAUL 54/M 21876 IVDP L4L5 LEFT L5 NERVE ROOT PC EXTRUSION 7 3 3 3 2 2
52 27/8/2018 FARIDA 52/F 12354 IVDP L4L5 RIGHT L5 NERVE ROOT PC PROTRUSION 6 3 3 3 3 2
53 10.09.2018 KANAGA 43/F 29187 IVDP L3L4 RIGHT L4 NERVE ROOT FORAMINAL LOCALIZED 7 2 3 3 2 2
54 15.09.2018 DHANABAGYAM 41/F 59263 IVDP L4L5 L5S1 LEFT L5S1 NERVE ROOT PC EXTRUSION 8 3 3 3 2 2
55 28/9/2018 VARITHA 37/F 14514 IVDP L4L5 B/L B/L L5 NERVE ROOT PL EXTRUSION 7 3 3 3 3 3
IVDP L4-L5
56 14.10.2018 PATTU LAKSHMI 32/F 35049 L5-S1 RIGHT S1 NERVE ROOT FORAMINAL PROTRUSION 7 3 4 4 6
57 21.10.2018 THULAKAMMAL 45/F 28686 IVDP L5S1 LEFT S1 NERVE ROOT PL PROTRUSION 7 2 1 1 1 1
58 25.10 .2018 VIMALA 22/F 30927 IVDP L3L4 L4L5 LEFT L4 L5 NERVE ROOT PL EXTRUSION 8 3 2 2 2 2
IVDP L4-L5
59 27. 10. 18 SWARNALATHA 38/F 36275 L5-S1 LEFT S1 NERVE ROOT PC EXTRUSION 6 3 3 3 7
60 30.10.18 SHANTHAMANI 54/F 41213 IVDP L4L5 RIGHT L5 NERVE ROOT PC EXTRUSION 7 3 2 2 2 2

* PC – Postero Central Disc

* PL – Postero Lateral Disc