The Effect of Subcutaneous Fat Tissue Thickness on Lumbar Transforaminal Epidural Steroid Injection Treatment Success

Nerve compression due to lumbar disc herniation and related radicular pain is a very common condition when the lifetime prevalence is considered. Lumbosacral radicular pain can be defined as pain originating from the lumbar level and spreading to the lower extremities along the distribution area of one or more spinal nerves. It is thought that the mechanical pressure of the disc material herniated to the dorsal nerve root or ganglion or the inflammation created by the chemokines and enzymes in the disc are involved in the pain formation mechanism.

Various methods such as medical agents, physical therapy modalities, epidural steroid injections and surgical methods can be used in the treatment of the related condition. Epidural injections have been used for the treatment of lower back and lower extremity pain since about 1900. Epidural injections exert their effects through the anti-inflammatory and neural membrane stabilizing effects of steroids, as well as by local anesthetics increasing blood flow to the ischemic spinal root and by the removal of cytokines from the area by the injection material. Epidural injections can be performed with various different approaches, including caudal, interlaminar and transforaminal. Among these approaches, the transforaminal approach is the most recently developed approach in the late 1990s, which allows drugs to be administered directly to the pathology area.

The effect of obesity, which is one of the factors thought to predispose to low back pain and lumbosacral radicular pain, has been evaluated in various studies and it has been found that it is positively correlated with low back pain and is an independent risk factor for lumbar herniation. So, does obesity have an effect on the success of transforaminal epidural steroid injection treatment? According to the literature, no significant effect on treatment success has been demonstrated.

Although the body mass index, which is used in the evaluation of obesity, has provided us important information about the health of the person in general for a long time, it is now thought to lead to an incomplete assessment. Because it does not provide information about body composition ratios (fat amount / lean body mass). Studies have shown that there is a high correlation between the percentage of body fat and the thickness of the subcutaneous fat tissue in the lumbar region, and there is a significant relationship between the lumbar region subcutaneous fat tissue thickness (especially L1-L2 level) and the degree of intervertebral disc degeneration and vertebral surface change. From this point of view, in another study, the L1-L2 disc level subcutaneous fat tissue thickness, was called the subcutaneous fat index, and the cut-off values that showed a significant relationship with spinal degeneration were determined.

In the study we planned, in cases of spinal radicular pain (etiologically caused by intervertebral disc herniation), body mass index, lumbar level subcutaneous fat tissue thickness and subcutaneous fat index data whether be or be not correlated with treatment effectiveness/success in patients who received transforaminal epidural steroid injection, and if so, the level of significance intended to work. Before applying for surgery, we aim to develop a practical approach that can be used by relevant clinicians and contribute to the literature, which can predict 'what level of treatment success can we achieve in which patient?' with this injection method.

Study Overview

• Status: Completed
• Conditions: Obesity; Lumbar Disc Herniation; Radiculopathy Lumbar
• Intervention / Treatment: Procedure: Transforaminal Epidural Steroid Injection

• Study Type: Observational
• Enrollment (Actual): 52

Contacts and Locations

• Study Contact: Name: Savaş Şencan; Phone Number: +90 537 066 5713; Email: savas-44@hotmail.com
• Study Contact Backup: Name: Ahmet Saç; Phone Number: +90 534 696 6745; Email: sacahmet@gmail.com

Study Locations

• Turkey
  • Istanbul, Turkey
    • Marmara University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 63 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

The study group will consist of patients who are planned to receive transforaminal epidural steroid injection treatment by the clinician, and who want to participate in the study.

Description

Inclusion Criteria:

• Being between the ages of 18-65
• Patients with a diagnosis of lumbosacral radiculopathy with low back and leg pain for at least 3 months that did not respond to other treatment methods
• Çalışmaya katılma için gönüllü olmak ve onam formu imzalamış olmak
• Presence of single root nerve compression due to MR imaging-proven single-level lumbar disc herniation
• Completeness of 3-month clinical evaluation data after the procedure

Exclusion Criteria:

• Having had lumbosacral surgery
• Multilevel disc herniation
• Presence of foraminal disc herniation
• Presence of local and/or systemic infection
• History of malignancy
• Presence of spinal stenosis
• Pregnancy
• Presence of known coagulopathy
• Having a known psychiatric illness diagnosis
• History of allergy to any of the injection substances
• Epidural steroid injection in the last 3 months

Study Plan

How is the study designed?

Design Details

• Observational Models: Case-Control
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Those who had TFESI and whose subcutaneous fat index was above the cut-off value; Those who are above the subcutaneous fat index cut-off values (9.4 mm in men, 8.45 mm in women) will be included in this group.	Procedure: Transforaminal Epidural Steroid Injection; Patients are placed in the prone position, with a pillow under their abdomen (to reduce lumbar lordosis) and taken to the operating table. The procedure area is cleaned 3 times with povidone-iodine antiseptic and covered with a sterile cover. In order to view the foramen to be processed, the fluoroscopy arm is evaluated at AP-oblique / cranial or caudal angles to obtain an optimal image. Local anesthetic (3 cc 2% prilocaine) is injected into the skin and subcutaneous tissue. The spinal Quincke 21-gauge 90 mm needle is advanced by targeting the relevant foramen under the guidance of fluoroscopy image. Needle position is confirmed by taking a lateral view. Needle aspiration is checked for blood. 1-2 ml of contrast material is injected to confirm that there is no vascular distribution and that it is in the epidural space. When distribution without vascular invasion is observed, an injection of a mixture of 10 mg dexamethasone, 1 cc saline and 1 cc (0.5%) bupivacaine is performed.
Those who had TFESI and whose subcutaneous fat index was below the cut-off value; Those who are below the subcutaneous fat index cut-off values (9.4 mm in men, 8.45 mm in women) will be included in this group.	Procedure: Transforaminal Epidural Steroid Injection; Patients are placed in the prone position, with a pillow under their abdomen (to reduce lumbar lordosis) and taken to the operating table. The procedure area is cleaned 3 times with povidone-iodine antiseptic and covered with a sterile cover. In order to view the foramen to be processed, the fluoroscopy arm is evaluated at AP-oblique / cranial or caudal angles to obtain an optimal image. Local anesthetic (3 cc 2% prilocaine) is injected into the skin and subcutaneous tissue. The spinal Quincke 21-gauge 90 mm needle is advanced by targeting the relevant foramen under the guidance of fluoroscopy image. Needle position is confirmed by taking a lateral view. Needle aspiration is checked for blood. 1-2 ml of contrast material is injected to confirm that there is no vascular distribution and that it is in the epidural space. When distribution without vascular invasion is observed, an injection of a mixture of 10 mg dexamethasone, 1 cc saline and 1 cc (0.5%) bupivacaine is performed.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Treatment Success	More than 50% reduction in NRS (Numeric Rating Scale) and more than 40% reduction in ODI (Oswestry Disability Index) will be taken as criteria. (NRS is a scale that is defined as '0' = no pain, '10' = the most severe, unbearable pain, in which the patient gives points between '0' and '10' for the low back and leg pain felt by the patient.) (ODI is a deficiency/competence index that includes assessments grouped according to the types of daily activities in patients with low back pain.)	3 weeks after TFESI
Treatment Success	More than 50% reduction in NRS (Numeric Rating Scale) and more than 40% reduction in ODI (Oswestry Disability Index) will be taken as criteria. (NRS is a scale that is defined as '0' = no pain, '10' = the most severe, unbearable pain, in which the patient gives points between '0' and '10' for the low back and leg pain felt by the patient.) (ODI is a deficiency/competence index that includes assessments grouped according to the types of daily activities in patients with low back pain.)	3 months after TFESI

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
NRS (Numeric Rating Scale)	NRS is a scale that is defined as '0' = no pain, '10' = the most severe, unbearable pain, in which the patient gives points between '0' and '10' for the low back and leg pain felt by the patient.	Before TFESI / 1 Hour After TFESI / 3 weeks after TFESI / 3 months after TFESI
ODI (Oswestry Disability Index)	ODI is a deficiency/competence index that includes assessments grouped according to the types of daily activities in patients with low back pain.	Before TFESI / 3 weeks after TFESI / 3 months after TFESI
SF-12 (12-item Short Form Survey)	SF-12 is a scale that evaluates the patient's quality of life.	Before TFESI / 3 weeks after TFESI / 3 months after TFESI

Collaborators and Investigators

• Sponsor: Marmara University

Study record dates

Study Major Dates

• Study Start (Actual): October 10, 2022
• Primary Completion (Actual): May 11, 2023
• Study Completion (Actual): August 11, 2023

Study Registration Dates

• First Submitted: September 22, 2022
• First Submitted That Met QC Criteria: September 22, 2022
• First Posted (Actual): September 27, 2022

Study Record Updates

• Last Update Posted (Actual): April 12, 2024
• Last Update Submitted That Met QC Criteria: April 11, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: Obesity; Transforaminal Epidural Injection; Radicular Pain; Subcutaneous Fat Tissue Thickness; Subcutaneous Fat Index; Lumbar Disc Hernia
• Additional Relevant MeSH Terms: Nervous System Diseases; Musculoskeletal Diseases; Neuromuscular Diseases; Peripheral Nervous System Diseases; Pathological Conditions, Anatomical; Spinal Diseases; Bone Diseases; Hernia; Intervertebral Disc Displacement; Radiculopathy
• Other Study ID Numbers: MU-AS-SŞ-22.09.22

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No