- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05793528
The Effect of Ultrasound Guidance on Radiation Dose and Procedure Time in Lumbar Transforaminal Epidural Injection
Low back pain is one of the leading causes of disability, and its social burden and economic cost are quite high. Although there are many causes that can lead to low back pain, radicular pain, which develops mostly secondary to lumbar disc hernias, is one of the most common pathologies. Epidural corticosteroid and local anesthetic injections are an important treatment option in the treatment of lumbar radicular pain that does not respond to conservative methods.
For fluoroscopy-guided epidural injections; transforaminal, interlaminar and caudal approaches may be preferred. It is accepted as the superiority of the transforaminal approach that it allows access to the area of pathology, thus to the anterior epidural area where inflammatory mediators are more concentrated, and that it can spread to the target specifically around the inflamed nerve roots.
In transforaminal epidural injections, the use of ultrasound as the sole imaging tool throughout the entire procedure is still not appropriate, as subbony structures cannot be visualized. However, ultrasound can be integrated at any stage of the process. Thus, the relatively inexpensive cost, portability, and ability to show non-osseous tissues of ultrasonography are utilized, particularly in terms of reducing radiation exposure.
Gofeld et al. claimed that ultrasound-guided transforaminal epidural injection could be performed by targeting the posterior part of the vertebral body. However, in cases where the lamina is wide and covers the posterior of the vertebral body, it may not be possible to sonographically view the vertebral body. In addition, although the intervertebral disc is differentiated from the corpus, loss of fluid content in the elderly can cause acoustic shadowing in the disc. This may result in accidental intra-disc injections. Finally, even if the target point is reached, it is not possible to show intravascular spread at this level ultrasonographically. Therefore, in our opinion, this method is unreliable for transforaminal epidural injections. Another study used ultrasound and fluoroscopy together for transforaminal epidural injections. After imaging the lamina of the relevant vertebral level sonographically, the needle is directed to the lateral edge of the lamina, then fluoroscopic imaging is performed after it passes under the lamina with the loss of resistance technique. However, it should be known that the loss of resistance technique is not a suitable and reliable method in transforaminal injections. In addition, since it is not known how far the lamina has progressed after it has passed under the bone, in other words, imaging guidance is disabled in this part of the process.
In our clinic, we use ultrasonography and fluoroscopy methods in an integrated way (hybrid method) for transforaminal epidural injections. For this purpose, we proceed to fluoroscopic imaging immediately after the spinal needle is advanced to the lateral edge of the lamina at the vertebral level where there is pathology with ultrasound. We think that with this method, we continue to stay in the safe window and reduce the radiation dose and procedure time. Based on this, we determined the aim of this study as the effect of including ultrasonography guidance in transforaminal epidural injections on radiation dose and procedure time.
Study Overview
Status
Conditions
Study Type
Enrollment (Anticipated)
Contacts and Locations
Study Contact
- Name: Yucel Olgun
- Phone Number: +905543121246
- Email: dryucelolgun@gmail.com
Study Locations
-
-
-
Istanbul, Turkey
- Marmara University
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Sampling Method
Study Population
Description
Inclusion Criteria:
- Being between the ages of 18-70
- Radicular low back pain
- Failure to respond to conservative treatments
- Pain intensity NRS >3/10
- Lumbar nerve root compression due to disc herniation in lumbar MRI
- Agree to participate in the research
Exclusion Criteria:
- Patients younger than 18 years old and over 70 years old
- Patients describing only localized pain in the lower back without radiating to the lower extremities
- Those with nerve root compression due to reasons other than disc herniation
- Those with spondylolisthesis
- Those with transitional vertebrae
- Pregnancy
- Patients with a body mass index over 30
- Patients with bleeding diathesis
- Having a known psychiatric illness diagnosis
- History of allergy to any of the injection substances
Study Plan
How is the study designed?
Design Details
Cohorts and Interventions
Group / Cohort |
Intervention / Treatment |
---|---|
Those who had lumbar radicular pain
Patients with lumbar radicular pain identified by inclusion and exclusion criteria
|
The patients are positioned prone.
The injection site is cleaned with povidone-iodine 3 times and a sterile drape was applied.
Short-acting local anesthesia (3 mL of 2% prilocaine) is applied to the skin and subcutaneous tissue.
A 3.5-inch, 22-gauge spinal needle is inserted just below the pedicle.
It is advanced into the subpedicular space using the coaxial technique under the intermittent guidance of fluoroscopy.
The needle position is confirmed through a lateral view.
Using lateral views, the needle is placed at the posterior one-third of the foramen.
Using the anteroposterior view, one to 2 mL of the contrast agent (300 mg/50 mL iohexol) is given and the distribution pattern is visualized.
Once the epidural distribution of the contrast agent is confirmed without vascular flow, a mixture of 8 mg (two mL) of dexamethasone, 1 mL of physiological saline, and 1 mL (0.5%) of bupivacaine hydrochloride is injected.
The patients are positioned prone placed.
Following the provision of aseptic conditions, the spinous process of the vertebral midline is visualized using a low-frequency convex ultrasound probe.
The lateral edge of the relevant vertebral lamina is visualized by sonographic scanning in the horizontal plane.
Local anesthesia is applied to the skin and subcutaneous tissue.
A 3.5-inch, 22-gauge spinal needle is advanced to the lateral edge of the relevant vertebral lamina under ultrasound image guidance.
Then, anteroposterior imaging is performed with fluoroscopy to confirm needle localization when the lamina margin is reached, and the needle is guided into the foramen under the guidance of fluoroscopy.
The contrast agent is given and the distribution pattern is visualized.
Once the epidural distribution of the contrast agent is confirmed without vascular flow, a mixture of 2 mL of dexamethasone, 1 mL of physiological saline, and 1 mL (0.5%) of bupivacaine hydrochloride is injected.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in NRS (Numeric Rating Scale)
Time Frame: at first hour
|
≥50% reduction in the NRS scores at first hour relative to the initial NRS scores.
|
at first hour
|
Radiation Dose
Time Frame: at first hour
|
Radiation dose during the TFESI
|
at first hour
|
Radiation Time
Time Frame: at first hour
|
Radiation time during the TFESI
|
at first hour
|
Procedure Time
Time Frame: at first hour
|
Procedure time during the TFESI
|
at first hour
|
Collaborators and Investigators
Sponsor
Publications and helpful links
General Publications
- Yang G, Liu J, Ma L, Cai Z, Meng C, Qi S, Zhou H. Ultrasound-guided Versus Fluoroscopy-controlled Lumbar Transforaminal Epidural Injections: A Prospective Randomized Clinical Trial. Clin J Pain. 2016 Feb;32(2):103-8. doi: 10.1097/AJP.0000000000000237.
- Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010 Aug;11(8):1149-68. doi: 10.1111/j.1526-4637.2010.00908.x.
- Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013 May-Jun;38(3):175-200. doi: 10.1097/AAP.0b013e31828ea086.
- Rivera CE. Lumbar Epidural Steroid Injections. Phys Med Rehabil Clin N Am. 2018 Feb;29(1):73-92. doi: 10.1016/j.pmr.2017.08.007.
- Vlaeyen JWS, Maher CG, Wiech K, Van Zundert J, Meloto CB, Diatchenko L, Battie MC, Goossens M, Koes B, Linton SJ. Low back pain. Nat Rev Dis Primers. 2018 Dec 13;4(1):52. doi: 10.1038/s41572-018-0052-1.
- Patrick N, Emanski E, Knaub MA. Acute and Chronic Low Back Pain. Med Clin North Am. 2016 Jan;100(1):169-81. doi: 10.1016/j.mcna.2015.08.015.
- Shim E, Lee JW, Lee E, Ahn JM, Kang Y, Kang HS. Fluoroscopically Guided Epidural Injections of the Cervical and Lumbar Spine. Radiographics. 2017 Mar-Apr;37(2):537-561. doi: 10.1148/rg.2017160043. Epub 2016 Dec 9.
- Manchikanti L, Benyamin RM, Falco FJ, Kaye AD, Hirsch JA. Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review. Clin Orthop Relat Res. 2015 Jun;473(6):1940-56. doi: 10.1007/s11999-014-3490-4.
- Hong JH, Park EK, Park KB, Park JH, Jung SW. Comparison of clinical efficacy in epidural steroid injections through transforaminal or parasagittal approaches. Korean J Pain. 2017 Jul;30(3):220-228. doi: 10.3344/kjp.2017.30.3.220. Epub 2017 Jun 30.
- Gofeld M, Bristow SJ, Chiu SC, McQueen CK, Bollag L. Ultrasound-guided lumbar transforaminal injections: feasibility and validation study. Spine (Phila Pa 1976). 2012 Apr 20;37(9):808-12. doi: 10.1097/BRS.0b013e3182340096.
- Provenzano DA, Narouze S. Sonographically guided lumbar spine procedures. J Ultrasound Med. 2013 Jul;32(7):1109-16. doi: 10.7863/ultra.32.7.1109. No abstract available.
Study record dates
Study Major Dates
Study Start (Anticipated)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- MU-SK-YO-20.03.23
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
Clinical Trials on Lumbar Disc Herniation
-
Shanghai General Hospital, Shanghai Jiao Tong University...RecruitingLumbar Disc Herniation | Lumbar Disc DegenerationChina
-
Shin Kong Wu Ho-Su Memorial HospitalTerminatedLumbar Disc Herniation | Lumbar Traction | Spinal Manipulation | Lumbar SurgeryTaiwan
-
Intrinsic TherapeuticsActive, not recruitingLumbar Disc Herniation | Annular Disc Tear | Annular Tear of Lumbar DiscBelgium, Germany
-
Allina Health SystemTwin Cities Spine CenterRecruitingLumbar Disc Herniation | Lumbar Spinal Stenosis | Lumbar Spondylolisthesis | Lumbar Disc DiseaseUnited States
-
Holger JoswigCompletedLumbar Disc Herniation | Cervical Disc HerniationSwitzerland
-
Akdeniz UniversityCompletedLumbar Disc Herniation | Lumbar Spine SurgeryTurkey
-
Medtronic Spinal and BiologicsCompletedDegenerative Disc Disease, Lumbar | Disc Herniation, LumbarCzech Republic, Slovakia, Venezuela
-
Jaseng Medical FoundationRecruitingLumbar Disc HerniationKorea, Republic of
-
Firat UniversityRecruiting
-
Eastern Mediterranean UniversityRecruiting
Clinical Trials on Fluoroscopy Guided Transforaminal Epidural Steroid Injection
-
ArthroCare CorporationCompletedRadicular PainUnited States
-
Istanbul Medeniyet UniversityMarmara UniversityRecruitingLumbosacral RadiculopathyTurkey
-
Marmara UniversityRecruitingMetabolic Syndrome | Herniated Disk LumbarTurkey
-
Marmara UniversityRecruitingFibromyalgia | Herniated Disk LumbarTurkey
-
State University of New York - Upstate Medical...WithdrawnIntervertebral Disc Displacement | Radiculopathy | Spinal StenosisUnited States
-
Mansoura UniversityCompleted
-
Marmara UniversityRecruitingLumbar Radiculopathy | Trigger Point Pain, MyofascialTurkey
-
Kyungpook National University HospitalUnknownAnalgesia, EpiduralKorea, Republic of
-
Johns Hopkins UniversityWithdrawn
-
Marmara UniversityCompletedLow Back Pain | Radiculopathy | Failed Back Surgery Syndrome | Epidural FibrosisTurkey