ЕФЕКТИВНОСТА НА ПЕРИРАДИКУЛAРНАТА ТЕРАПИЈА ПОД ВОДСТВО НА КОМПЈУТЕРИЗИРАНА ТОМОГРАФИЈА КАЈ ПАЦИЕНТИ СО ХРОНИЧНА ЛУМБАЛНА БОЛКА И РАДИКУЛОПАТИЈА
Date Issued
2022-03-21
Author(s)
Abstract
Introduction: Low back pain is one of the most common conditions that every person faces in
his life and one of the most common reasons to visit a doctor. The frequency is so high that it is
believed that about 80% of the population have at least one episode of low back pain in life of
various degrees and forms.
Life expectancy of lower back pain is estimated at 13-40% in industrialized countries with a one year prevalence of 15-45%, the incidence in adults is 5% per year, with a peak of 35 to 55 years
of age for the most part in the working age population.
Chronic lumbar pain and radiculopathy is a clinical lumbar pain syndrome followed by limb pain
involving sensory or motor deficits on the affected side for more than 12 weeks.
The modern treatment requires a multiplicity of approach that includes physical therapy,
minimally invasive techniques, and sometimes a classic surgical approach. Diskal herniations,
spinal stenosis, degenerative diseases with or without disc herniation, and postoperative lumbar
pain syndrome are the most common conditions responsible for chronic persistent lumbar pain
and radiculopathy. Minimally invasive techniques including periradicular therapy are the most
commonly used nonvascular interventions to manage chronic lumbar pain and painful radicular
syndrome.
Many studies show a significant reduction in lumbar pain and radiculopathy shortly or for a long
time after epidural application.
Main objectives of the study: To evaluate the efficacy of PRT (Periradicular Therapy) in
patients with chronic lumbar pain and radiculopathy most commonly caused by disc herniation,
disc osteophyte complex or central lumbar stenosis in the lumbar segment with the following
objectives:
Secondary goals:
• To see if there is an association between the duration of pain before the intervention and the
degree of its reduction with PRT after 2 weeks, 3 months and 6 months.
• Assess whether there is a possible association between age, sex, location of the lesion (pain)
and the degree of effectiveness of the intervention (degree of pain reduction).
• To determine the group of demographic, radiological and clinical factors that are associated
with the effectiveness (success) of the intervention.
• Assess the degree of pain reduction and the degree of functionality of the patients depending on
the type of hernias (foraminarian, extraformaramin, posterolateral) after PRT.
11
2. To assess the quality of life in patients with lumbar pain and radiculopathy before and after the
intervention.
Study design: According to the design, the study is non-randomized (patients were included as
indicated), prospective, interventional, which includes prospective follow-up of 166 male and
female subjects with chronic lumbar or radicular pain, all treated with PRT.
Materials and methods: The clinical study was conducted in the PHI CGH " 8 September " of
the Department of Diagnostic and Interventional Radiology. The study included prospective
follow-up of 166 male and female subjects with chronic lumbar or radicular pain.
All patients underwent MRI (magnetic resonance imaging) at least one month before the
intervention and central canal stenosis, spondylolisthesis, or disc herniation with or without
nerve root compression were demonstrated. Subcutaneous application of Lidocaine 3ml as well
as Bupivacaine 2ml and Kenalog 2ml at the level of the lateral epidural space was used for all
subjects. Medical application (Bupuvacaine and Kenalog) was monitored by 16-slice CT
(computed tomography).The degree of pain intensity was scored according to the VAS scale
(visual analog scale) – The National Initiative on Pain Control ™ (NIPC ™) which included
mild, moderate, severe and very severe pain.The degree of improvement was presented as
excellent (over 75%,) good (50-70%), medium (25-49%), poor (less than 25%). Functional and
working status were assessed according to Oswestry Disability index 2.0 (ODI). Follow-up of
treated patients was after 2 weeks, 3, 6 months.
Results: There was a statistically significant reduction in the average value of VAS and ODI.
For VAS good response – (≥ 50%) was observed at 51.81% after 2 weeks, 54.22% after 3
months and 59.04% after 6 months. For ODI higher or equal to 40% in 22.29% after 2 weeks,
after the 3rd 13.86%, and after the 6th month 8.43%.The number of patients with a good VAS
and ODI response was higher when the pain duration interval was shorter. After 2 weeks in
patients with pain duration up to 3 months the improvement was excellent in 32 (58.18), after 3
months 41 (74.55) and after 6 months 41 (74.55), in contrast to patients with pain over 1 year
who showed excellent improvement at 2 (5.71) after 2 weeks, 41 (74.55) after 3 months, and 41
(74.55) after 6 months. The mean percentage improvement after 6 months of intervention was
highest in patients with localization of pain at level L4-L5 (69.69 ± 29.7), and lowest 51.52 ±
30.1 in patients with localization of pain at level L5-S1.At the end of follow-up patients, the
mean ODI values were 27.67 ± 25.2 in patients with L3-L4 level pain, as opposed to patients
with L2-L3 level pain with an average ODI value of 46.75 ± 39.02. The mean percentage
improvement after 6 months was highest in patients with extraforaminal herniations (65.25 ±
28.8) and lowest in patients with central canal stenosis (45.21 ± 25.7). ODI lower than 40%, 2
weeks after the intervention was registered most often in patients with extraforaminal herniations
– 90% (16) and most rarely in patients with central canal stenosis – 58.6% (10). Patients with a
lower degree of nerve root compression had a significant improvement. The percentage
12
improvement after 6 months post-intervention was highest in patients without nerve root
compression (86.25 ± 19.2), followed by patients with first, second, third, and fourth degree
compression (78.1 ± 22.7, 57.2 ± 28.5, 46.4 ± 49.8, and 34.6). ± 33.2, respectively). The ODI
index after 6 months of intervention presented the lowest values in patients without nerve root
compression (10.5 ± 7.5), followed by patients with first, second, third and fourth degree of
compression (14.6 ± 9.4, 25.7 ± 20.2, 40.4 ± 23.8, and 64 ± 33.8 respectively.
Conclusion: CT performed PRT in patients with lumbar pain and radiculopathy is a safe,
effective therapy and procedure and it is best to do it as soon as the symptoms appear. The
benefit is greater in patients with less compression of the nerve radix. In patients treated with
PRT there is a reduction in the use of analgesics and anti-inflammatory drugs and a significant
improvement in quality of life.
Keywords: periraductal therapy, chronic lumbar pain, radiculopathy, corticosteroids, PRT, CT
his life and one of the most common reasons to visit a doctor. The frequency is so high that it is
believed that about 80% of the population have at least one episode of low back pain in life of
various degrees and forms.
Life expectancy of lower back pain is estimated at 13-40% in industrialized countries with a one year prevalence of 15-45%, the incidence in adults is 5% per year, with a peak of 35 to 55 years
of age for the most part in the working age population.
Chronic lumbar pain and radiculopathy is a clinical lumbar pain syndrome followed by limb pain
involving sensory or motor deficits on the affected side for more than 12 weeks.
The modern treatment requires a multiplicity of approach that includes physical therapy,
minimally invasive techniques, and sometimes a classic surgical approach. Diskal herniations,
spinal stenosis, degenerative diseases with or without disc herniation, and postoperative lumbar
pain syndrome are the most common conditions responsible for chronic persistent lumbar pain
and radiculopathy. Minimally invasive techniques including periradicular therapy are the most
commonly used nonvascular interventions to manage chronic lumbar pain and painful radicular
syndrome.
Many studies show a significant reduction in lumbar pain and radiculopathy shortly or for a long
time after epidural application.
Main objectives of the study: To evaluate the efficacy of PRT (Periradicular Therapy) in
patients with chronic lumbar pain and radiculopathy most commonly caused by disc herniation,
disc osteophyte complex or central lumbar stenosis in the lumbar segment with the following
objectives:
Secondary goals:
• To see if there is an association between the duration of pain before the intervention and the
degree of its reduction with PRT after 2 weeks, 3 months and 6 months.
• Assess whether there is a possible association between age, sex, location of the lesion (pain)
and the degree of effectiveness of the intervention (degree of pain reduction).
• To determine the group of demographic, radiological and clinical factors that are associated
with the effectiveness (success) of the intervention.
• Assess the degree of pain reduction and the degree of functionality of the patients depending on
the type of hernias (foraminarian, extraformaramin, posterolateral) after PRT.
11
2. To assess the quality of life in patients with lumbar pain and radiculopathy before and after the
intervention.
Study design: According to the design, the study is non-randomized (patients were included as
indicated), prospective, interventional, which includes prospective follow-up of 166 male and
female subjects with chronic lumbar or radicular pain, all treated with PRT.
Materials and methods: The clinical study was conducted in the PHI CGH " 8 September " of
the Department of Diagnostic and Interventional Radiology. The study included prospective
follow-up of 166 male and female subjects with chronic lumbar or radicular pain.
All patients underwent MRI (magnetic resonance imaging) at least one month before the
intervention and central canal stenosis, spondylolisthesis, or disc herniation with or without
nerve root compression were demonstrated. Subcutaneous application of Lidocaine 3ml as well
as Bupivacaine 2ml and Kenalog 2ml at the level of the lateral epidural space was used for all
subjects. Medical application (Bupuvacaine and Kenalog) was monitored by 16-slice CT
(computed tomography).The degree of pain intensity was scored according to the VAS scale
(visual analog scale) – The National Initiative on Pain Control ™ (NIPC ™) which included
mild, moderate, severe and very severe pain.The degree of improvement was presented as
excellent (over 75%,) good (50-70%), medium (25-49%), poor (less than 25%). Functional and
working status were assessed according to Oswestry Disability index 2.0 (ODI). Follow-up of
treated patients was after 2 weeks, 3, 6 months.
Results: There was a statistically significant reduction in the average value of VAS and ODI.
For VAS good response – (≥ 50%) was observed at 51.81% after 2 weeks, 54.22% after 3
months and 59.04% after 6 months. For ODI higher or equal to 40% in 22.29% after 2 weeks,
after the 3rd 13.86%, and after the 6th month 8.43%.The number of patients with a good VAS
and ODI response was higher when the pain duration interval was shorter. After 2 weeks in
patients with pain duration up to 3 months the improvement was excellent in 32 (58.18), after 3
months 41 (74.55) and after 6 months 41 (74.55), in contrast to patients with pain over 1 year
who showed excellent improvement at 2 (5.71) after 2 weeks, 41 (74.55) after 3 months, and 41
(74.55) after 6 months. The mean percentage improvement after 6 months of intervention was
highest in patients with localization of pain at level L4-L5 (69.69 ± 29.7), and lowest 51.52 ±
30.1 in patients with localization of pain at level L5-S1.At the end of follow-up patients, the
mean ODI values were 27.67 ± 25.2 in patients with L3-L4 level pain, as opposed to patients
with L2-L3 level pain with an average ODI value of 46.75 ± 39.02. The mean percentage
improvement after 6 months was highest in patients with extraforaminal herniations (65.25 ±
28.8) and lowest in patients with central canal stenosis (45.21 ± 25.7). ODI lower than 40%, 2
weeks after the intervention was registered most often in patients with extraforaminal herniations
– 90% (16) and most rarely in patients with central canal stenosis – 58.6% (10). Patients with a
lower degree of nerve root compression had a significant improvement. The percentage
12
improvement after 6 months post-intervention was highest in patients without nerve root
compression (86.25 ± 19.2), followed by patients with first, second, third, and fourth degree
compression (78.1 ± 22.7, 57.2 ± 28.5, 46.4 ± 49.8, and 34.6). ± 33.2, respectively). The ODI
index after 6 months of intervention presented the lowest values in patients without nerve root
compression (10.5 ± 7.5), followed by patients with first, second, third and fourth degree of
compression (14.6 ± 9.4, 25.7 ± 20.2, 40.4 ± 23.8, and 64 ± 33.8 respectively.
Conclusion: CT performed PRT in patients with lumbar pain and radiculopathy is a safe,
effective therapy and procedure and it is best to do it as soon as the symptoms appear. The
benefit is greater in patients with less compression of the nerve radix. In patients treated with
PRT there is a reduction in the use of analgesics and anti-inflammatory drugs and a significant
improvement in quality of life.
Keywords: periraductal therapy, chronic lumbar pain, radiculopathy, corticosteroids, PRT, CT
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