w w w . r b o . o r g . b r
Original
Article
Comparison
of
the
efficacy
of
transforaminal
and
interlaminar
radicular
block
techniques
for
treating
lumbar
disk
hernia
夽
Rodrigo
Rezende,
Charbel
Jacob
Júnior
∗,
Camila
Kill
da
Silva,
Igor
de
Barcellos
Zanon,
Igor
Machado
Cardoso,
José
Lucas
Batista
Júnior
HospitaldaSantaCasadeMisericórdia,Vitória,ES,Brazil
a
r
t
i
c
l
e
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n
f
o
Articlehistory:
Received2October2013 Accepted5December2013 Availableonline10March2015
Keywords:
Nerveblock
Intervertebraldiskdisplacement Lumbarpain
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Objective:Tocomparetheinterlaminarandtransforaminalblocktechniqueswithregardto thestateofpainandpresenceorabsenceofcomplications.
Method:Thiswasarandomizeddouble-blindprospectivestudy ofdescriptiveand com-parativenature,on40patientsofbothsexeswhopresentedlumbarsciaticpaindueto central-lateralorforaminaldiskhernias.Thepatientshadfailedtorespondto20 phys-iotherapysessions,butdidnotpresentinstability,asdiagnosedindynamicradiographic examinations.Thetypeofblocktobeusedwasdeterminedbymeansofadraw: trans-foraminal(group1;20patients)orinterlaminar(group2;20patients).
Results:Fortypatientswereevaluated(17males),withameanageof49years.Therewasa significantimprovementinthestateofpaininallpatientswhounderwentradicularblock usingbothtechniques,althoughthetransforaminaltechniquepresentedbetterresultsthan theinterlaminartechnique.
Conclusion:Bothtechniqueswereeffectiveforpainreliefandpresentedlowcomplication rates,butthetransforaminaltechniquewasmoreeffectivethantheinterlaminartechnique. ©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Comparac¸ão
da
eficácia
das
técnicas
transforaminal
e
interlaminar
de
bloqueio
radicular
feito
no
tratamento
de
hérnia
de
disco
lombar
Palavras-chave:
Bloqueionervoso Deslocamentododisco intervertebral
Dorlombar
r
e
s
u
m
o
Objetivo:Compararatécnicadebloqueiointerlaminarcomadebloqueiotransforaminal, quantoaoquadroálgicoeàpresenc¸aounãodecomplicac¸ões.
Método:Estudoprospectivo,decaráterdescritivoecomparativo,duplo-cegoerandomizado, emquesãosujeitos40pacientes,deambosossexos,portadores delombociatalgiapor hérniadedisco,dotipocentro-lateralouforaminal,semrespostaa20sessõesdefisioterapia
夽
WorkdevelopedatHospitaldaSantaCasadeMisericórdia,Vitória,ES,Brazil. ∗ Correspondingauthor.
E-mail:jcharbel@gmail.com(C.JacobJúnior). http://dx.doi.org/10.1016/j.rboe.2015.02.016
eseminstabilidade,diagnosticadaemexamederadiografiadinâmica.Otipodebloqueio, transforaminal(grupo1)ouinterlaminar(grupo2),aserfeitofoideterminadopormeiode sorteioeconstituiu20pacientesdogrupo1e20dogrupo2.
Resultados:Foramavaliados40pacientes,17dosexomasculino,médiade49anos,nosquais houvemelhoriasignificativadoquadroálgicoemtodosossubmetidosaobloqueioradicular emambasastécnicas,emboraatécnicatransforaminalapresentassemelhoresresultados quandocomparadacomainterlaminar.
Conclusão: Ambasastécnicassãoeficazes noalíviodadoreapresentambaixataxade complicac¸ão,masatransforaminalfoimaiseficazdoqueainterlaminar.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Lumbardiskherniaconsistsofdisplacementofthepulpous nucleus contained in the intervertebral disk through the fibrousring.Thisdisplacementmayleadtocompressionand irritation of the lumbar nerve roots and dural sac, which are characterized clinically by the pain known as sciatic pain.1
The etiology of sciatic pain is multifactorial. It can be causedbymechanicalcompressionoftheintervertebraldisk andbythereleaseofinflammatoryandnociceptivemediators comingfrom thepulpousnucleus.2–8 Ithasbeen estimated that2–3% ofthepopulation haslumbardisk hernias,with prevalenceof4.8%amongmenand2.5%amongwomenover theageof35years.Furthermore,itisthecommonest diagno-sisamongdegenerativealterationsofthelumbarspineand themaincauseofsurgery.1
Theinitialtreatmentfordiskherniainmostcasesis con-servative.Surgicaltreatmentisexceptional andisreserved onlyforcasesoflackofsuccessfromappropriateconservative treatment, progressiveneurologicaldeficit orcauda equina syndrome.1,9 Amongthevarioustechniquesthathavebeen describedintheliterature,minimallyinvasivesurgical pro-ceduresare nowvalued morehighlybecauseoftheirlower tissueaggression,shorterhospitalstay,loweranestheticrisk andearlierreturntoworkactivities.1,8–10
Rootblockis agood option amongthe minimally inva-sivetechniquesfortreatinglumbardiskhernia.Thismakes itpossibletoreducetheinflammatoryresponse,improvethe stateofpain, reducetheconsumptionofanalgesics, main-tainworkactivitiesandeliminatetheneedforsurgery,among mostindividuals.8,11–13
Forpatientswhoarerefractorytoappropriateconservative treatment,inanattempttopostponeoreventoavoidsurgery, rootblockcanbeindicated.Thiscanbedoneusing interlami-narandtransforaminaltechniques,orcaudally(viathesacral hiatus).1,14,15
However,onlyafewstudies intheliteraturehave com-paredtheinterlaminar andtransforaminaltechniqueswith a view to determining which of these is safer and more effective.Weconductedthe present study withthe aimof clarifying these doubts, so as to make a significant con-tribution toward alleviating the symptoms caused by disk hernias.
Method
Fortypatientswereevaluatedthroughadouble-blind random-izedprospectivestudy.
Thesampleselectiontookintoconsiderationthe follow-inginclusioncriteria:thepatientsneededtopresentlumbar sciatic pain secondary to disk hernia, with posterolateral, foraminalorextraforaminallocation,whichcould beeither limited to that location or extend beyond it, without any responseto20physiotherapysessions,andwithoutany insta-bility diagnosed in dynamic radiographic examinations of the lumbar spine. We took instability to be situations of vertebralplateau anglesgreater than18◦ andexcursionsof
morethan 3mmondynamiclumbarradiographsinlateral view.16
Patients were excluded if theypresentedlumbar sciatic pain with causes other than disk hernia, or if their pain respondedtoconservativetreatmentconsistingof20 physio-therapysessions,oriftheypresenteddynamicinstabilityon radiographs.
Avisualanalogscale(VAS)wasappliedtoallthepatients before and after receiving the block.4,6,17 The decision on whichblocktechniquewouldbeusedwasreachedbymeans ofadraw.Inthis,thenumber1representedthetransforaminal techniqueand2,theinterlaminartechnique.
Fig.1–Transforaminalblock.Imageobtainedvia fluoroscopy.
2mLof0.25%neo-bupivacaineand5mLofdistilledwater,was injected(Figs.1and2).3,5,6,12,18
Inthepatientswhounderwenttheinterlaminartechnique, wefollowedpositioningsimilartothatofthetransforaminal technique.Theupperedgeoftheipsilateralinferiorlamina wasmarkedoutandtheskinandtissuecoveringthetarget pointwereinfiltrated.Lossofresistanceisthemainsignof entryintotheepiduralspace.Afterinsertingtheneedleinto theperiduralspace,lateralfluoroscopicviewingwassetupin ordertoensurethatthetipoftheneedlewouldrestinthe posteriorepiduralspace. Following this,the same volumes ofthesamemedicationsasdescribedforthetransforaminal techniquewereinjected(Figs.3and4).
Aftertheblock hadbeen applied, thepatient madeuse ofthesame analgesicmedicationinthe hospitalandthen afterdischargefromthehospital.Thepreferredmedication wasdipyrone: 500mgevery sixhours inthe eventualityof pain.Only90daysafterreceivingtheblockwerethepatients referredformotorphysiotherapy.TheVASwasapplied imme-diatelyafterthepatientshadreceivedtheanalgesicblock,and then24hand7,21and90daysafterward.Complicationssuch asheadache,suddenpain,lumbalgia,temporarymotordeficit, permanentmotordeficitandextravasationoffluidwere eval-uatedclinicallyanddescribedinspecificmedicalfiles.19,20
Theevaluatorsbeforeand afterthe operationwere kept unawareofwhichtechniquehadbeenappliedtoeachpatient andtheyactedindependentlywithregardtothepost-block follow-up.
Weusedstatisticalanalysiswithparametricteststo eval-uate data with normal distribution, and this was done in analyzingtheresultsfromthetransforaminaltechnique.On
Fig.2–Transforaminalblock(inlateralview,foradequate viewingofthecontrastdistribution).Imageobtainedvia fluoroscopy.
Table1–ComparisonofthemeanVASscoreresultsbetweenthetechniques,foreachmeasurementtime.
Pre-block 24hafterwards 7daysafterwards 21daysafterwards 90daysafterwards
Transforaminaltechnique 8.81 0.71 1.05 2.33 3.84
Interlaminartechnique 8.89 0.89 1.53 3.65 4.88
pvalue 0.774 0.492 0.256 0.022 0.195
Mann–Whitneytest(comparisonbetweentwonon-normalindependentsamples).
Fig.4–Interlaminarblock(inlateralview,foradequate viewingofthecontrastdistribution).Imageobtainedvia fluoroscopy.
theotherhand,incasesinwhichthedistributionof probabil-itieswasnotnormal,weusednonparametrictests.Thiswas usedinanalyzingtheresultsfromtheinterlaminartechnique andforcomparingtheresultsbetweenthetwotechniques. Toestimatepost-blockmeans,anewdatasetwasgenerated usingthemeansfromtheresultsateachmeasurementtime, foreachpatient.
Results
Amongthe40patientsanalyzed,17weremaleandthemean agewas49.45 years.Twentyunderwent thetransforaminal technique and twenty, the interlaminar technique. In the groupwithinterlaminarblock,themeanagewas50.05years and,outofthe20patients,10weremale(50%)and10were female (50%). In the group with transforaminal block, the meanagewas48.85years,withsevenmalepatients(35%)and 13femalepatients(65%).
Incomparingthepre-blockVASvalueswiththetimesof 24hand7,21and90daysafterwards,inrelationtoboth tech-niques,wefoundstatisticallysignificantresults(p<0.05)at alltimes,independentofthetechniqueapplied,asshownin Fig.5.
10 9 8 7 6 5 4 3 2 1 0
Transforaminal Interlaminar
24 h afterwards
7 days afterwards21 days afterwards Pre-block
90 days afterwards
Mean post-block score
Fig.5–ComparisonofthemeanVASscoresbetweenthe differentmeasurementtimes,forthetwotechniquesused.
Table2–MeanVASscores–overallbeforeandafter block.
Meanpre-blockVASscore Meanpost-blockVASscore pvalue
8.85 2.32 0.000
p,statisticalsignificance.
Wilcoxontest(comparisonoftwodependentsamples).
In analyzingthe mean VAS scores atspecifictimes, we observedthatthetransforaminaltechniquepresentedbetter resultsatallthetimesanalyzed,asshowninTable1.
Inanalyzingthemeanpre-blockVASscoreandthemean finalpost-blockVASscorebetweenthetechniques,a statis-tical difference was observed between them, as shown in Table2.
Incomparingthemeanfinalpost-blockVASscorebetween thetransforaminalandinterlaminartechniques,weobserved thattherewasastatisticallysignificanthigherpainlevelin thetransforaminaltechnique,asdemonstratedinTable3.
Table3–Meanpost-blockVASscores,accordingto technique.
Pre-block After
transforaminal technique
After interlaminar technique
pvalue
8.85 1.97 2.71 0.027
p,statisticalsignificance.
Inrelationtothevariouscomplicationsthatexisted,we presenthereonlytwo:oneoflumbalgiainthegroupwiththe transforaminaltechniqueandoneofheadacheinthe inter-laminargroup.In thepatientwithheadache,therewasno puncturingoftheduramaterduringtheprocedure.
Discussion
Rootblockmaybeagoodpropaedeuticmethodforalleviating thesymptomsandreestablishingthequalityoflifeofpatients withdiskhernias.
Amongthevarioustechniquesthathavebeendescribed, theinterlaminar,transforaminalandcaudalmethodsarethe onesmostfrequentlyused.Intermsofefficacy,severalstudies havedemonstratedunequivocallythatepiduralinjectionsof steroidsareeffectivefortheintendedpurpose,althoughthe benefitsareonlyofshorttomediumduration.6,11,12,21
Inourstudy,wefoundthattherewasasignificant improve-mentinthestateofpainaftertheblockwasadministered, independent of the type of technique used. Most studies haveindicatedthattheadvantagesoftheinterlaminar tech-niqueareitsgreatersafetyandlowerlumbardiscomfort,22,23 whereasthe transforaminaltechniqueismoreeffectivefor reducingpainoverthelongterm.13–15,18,22–24
Inrelationtothestateofpain,weobservedthatalthough improvementsoccurredthroughbothofthetechniques ana-lyzed, thetransforaminal techniquewasmoreeffective for reducingthestateofpain,especiallyafterthe21stpost-block day,andthisimprovementpersisteduntiltheendofthestudy. Regardingthesafetyoftheprocedures,bothofthe tech-niqueswereseentobesafeinourstudyandtherewereno importantcomplications.
Wejudgethatrootblockisasafeoption,withgoodresults regardingalleviationofsciaticpaincausedbydiskhernias,for amoderatelengthoftime.
Conclusion
Thetransforaminalblocktechniquewasshowntobesaferand moreeffectivefortreatingsciaticpainsecondarytolumbar diskherniathantheinterlaminartechnique.
Funding
ScienceandTechnologySupportFundofVitória(FACITEC).
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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