Selective Nerve Root Injection
Abstract & Commentary
Commentary by Michael Rubin, MD, Professor of Clinical Neurology, New York Presbyterian Hospital-Cornell Campus, and Assistant Editor of Neurology Alert.
Synopsis: SNRIs may be performed safely with only minor side effects to be expected.
Source: Huston CW, et al. Complications and Side Effects of Cervical and Lumbosacral Selective Nerve Root Injections. Arch Phys Med Rehabil. 2005;86;277-283.
Among 160 consecutive patients who underwent cervical or lumbosacral selective nerve root injection (SNRI) for the diagnosis or treatment of radicular pain, 151 agreed to participate in a prospective, nonrandomized, controlled trial to determine the incidence of side-effects and complications using this procedure. Controls comprised of 60 patients who underwent no procedure. All SNRIs were performed under fluoroscopic guidance with 0.5 mL of 1% lidocaine for cervical diagnostic procedures and 1 mL of 2% lidocaine for lumbosacral diagnostic procedures. Therapeutic SNRIs were performed with 1.0 mL betamethasone and 0.5 mL of 1% lidocaine or 2.0mL betamethasone and 2.0 mL of 1% lidocaine for cervical and lumbosacral procedures, respectively. Peri-procedural complications were noted by the interventionalist in the fluoroscopy suite and by a registered nurse in the recovery room. At 1 week and 3 months follow-up, an independent physician administered a specifically designed questionnaire based on the medical literature, covering 24 categories of symptoms and directed to extract information indicative of possible side effects or complications. Results were analyzed using the Fisher exact test and Wilcoxon rank-sum test with significance defined as P < 0.05.
Of the 151 study patients, comprising 69 men and 82 women with a mean age of 47.4 years, 30.5% (n = 46) had undergone previous spine surgery. Three hundred six procedures were performed on the 151 patients; 89 cervical SNRIs in 37 patients and 217 lumbosacral SNRIs in 114 patients. No procedural complications were seen in 91% (n = 137), with the remainder reporting lightheadedness, nausea, increased radicular pain, headache or vasovagal reaction. Dural puncture occurred in 1 patient. In the recovery room, 39.4% (n = 60) answered positively to at least 1 question, but only increased pain at the injection site was significant compared to controls. At week 1, no significant difference was appreciated between lumbosacral patients and controls, but cervical patients experienced significantly more injection site pain and nonspecific, nonspinal headache. At 3 months, only 3 patients had complaints, including heartburn, fluid retention, or persistent increased spine pain. No serious complications including nerve root injuries, infection, or paralysis were seen. SNRIs may be performed safely with only minor side effects to be expected.
Commentary
Do we treat back pain differently in different ethnic groups or based on gender? Review of 5690 patients with degenerative lumbosacral spinal pathology enrolled in the National Spine Network (NSN) Outcomes Database, was undertaken to address this question (Taylor BA, et al. Spine. 2005;30;359-364). NSN comprises 20 US centers from San Francisco to New York and places in-between, and includes academic, hospital, and private practices in 89 clinical locations. The findings were revealing if not surprising. More than any other ethnic group, whites were more likely to have imaging studies requested or reviewed (76.6%). Women were more likely to undergo imaging studies than men, but men were significantly more likely to have surgery recommended (P < 0.031). At the first visit in particular, white men were almost twice as likely as non-white women to have surgery advised (probably better for the women!). Blacks and Hispanics were least likely to have surgery suggested or prescribed, compared to whites or Asians (P < 0.0001). This may not represent racial profiling, and some of the differences may be ascribed to managed care and insurance plan limitations, but attention to these discrepancies is warranted and needs to be addressed.
SNRIs may be performed safely with only minor side effects to be expected
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