Korean J Radiol.  2007 Apr;8(2):156-163. 10.3348/kjr.2007.8.2.156.

The Use of Magnetic Resonance Imaging to Predict the Clinical Outcome of Non-Surgical Treatment for Lumbar Interverterbal Disc Herniation

• Choi SJ
• Song JS
• Kim C
• Shin MJ
• Ryu DS
• Ahn JH
• Jung SM
• Park MS

• KMID: 1126839
• DOI: http://doi.org/10.3348/kjr.2007.8.2.156

Abstract

OBJECTIVE
We wanted to investigate the relationship between the magnetic resonance (MR) findings and the clinical outcome after treatment with non-surgical transforaminal epidural steroid injections (ESI) for lumbar herniated intervertebral disc (HIVD) patients. MATERIALS AND METHODS: Transforaminal ESI were performed in 91 patients (50 males and 41 females, age range: 13-78 yrs) because of lumbosacral HIVD from March 2001 to August 2002. Sixty eight patients whose MRIs and clinical follow-ups were available were included in this study. The medical charts were retrospectively reviewed and the patients were divided into two groups; the successful (responders, n = 41) and unsatisfactory (non-responders, n = 27) outcome groups. A successful outcome required a patient satisfaction score greater than two and a pain reduction score greater than 50%. The MR findings were retrospectively analyzed and compared between the two groups with regard to the type (protrusion, extrusion or sequestration), hydration (the T2 signal intensity), location (central, right/left central, subarticular, foraminal or extraforaminal), and size (volume) of the HIVD, the grade of nerve root compression (grade 1 abutment, 2 displacement and 3 entrapment), and an association with spinal stenosis. RESULTS: There was no significant difference between the responders and non-responders in terms of the type, hydration and size of the HIVD, or an association with spinal stenosis (p > 0.05). However, the location of the HIVD and the grade of nerve root compression were different between the two groups (p < 0.05). CONCLUSION: MRI could play an important role in predicting the clinical outcome of non-surgical transforaminal ESI treatment for patients with lumbar HIVD.

Keyword

Spine, intervertebral disks; Spine, MR

MeSH Terms

Adolescent
Adult
Aged
Chi-Square Distribution
Female
Humans
Intervertebral Disk Displacement/*drug therapy/pathology
Lumbar Vertebrae
*Magnetic Resonance Imaging
Male
Middle Aged
Predictive Value of Tests
Steroids/*therapeutic use
Treatment Outcome

Figure

• 

  Fig. 1 Transforaminal epidural steroid injection. A. Left anterior oblique radiograph for the right L5 transforaminal injection. The triangle is formed by the iliac crest (IC), the inferior margin of the right transverse process (TP), and the right S1 superior articular process (SAP). B. Left anterior oblique radiograph for needle positioning. The needle tip is inferior and lateral to the right L5 pedicle (p = pedicle). C. Epidurography shows the outline of the right L5 nerve root sleeve (arrows). D. Epidurography for the left L4 transforaminal injection. Contrast is seen outlining the left L4 nerve root sleeve (arrows). E. Epidurography for the right S1 transforaminal injection (arrows).

• 

  Fig. 2 Grade of nerve root compression. A. Grade I (abutment); the herniated disc abuts the nerve root, but the nerve root is in its normal position. B. Grade II (displacement); the herniated disc material displaces the nerve root, but the displaced nerve root can be seen by MRI. C. Grade III (entrapment); the nerve root is entrapped between the herniated disc and the lamina or facet. The entrapped nerve root is hardly detected by MRI.

• 

  Fig. 3 MRI of a 66-year-old man. Central disc herniation and grade I nerve root compression with a successful result. Mid-line sagittal (A) and axial (B) T2-weighted MR images show central disc protrusion (arrows). The disc was abutting both S1 nerve roots (arrowheads). Because the distribution of the patient's pain was along the right S1 dermatome and the electrodiagnostic study showed right S1 radiculopathy, we performed right S1 transforaminal ESI. The follow-up assessment seven months after injection showed a pain reduction greater than 50% and a patient satisfaction score of 2.

• 

  Fig. 4 MRI of a 56-year-old woman. Extraforaminal disc herniation with a successful result. She was suffering from severe posterior thigh and lateral leg pain with tingling sensations. Surgery was planned for this patient as conservative management with oral and intravenous medication had failed. A-C. The T1-weighted consecutive axial images. Extraforaminal disc herniation (arrow) is observed just above the level of the L5-S1 disc. Note that the disc is located at the extraforaminal course of the left L5 nerve (arrowheads). Left L5 transforaminal epidural steroid injection resulted in remarkable improvement and it removed the need for surgery. Eight months after injection the symptoms had disappeared and she was in a satisfactory condition.

• 

  Fig. 5 MRI of a 49-year-old man. Subarticular disc herniation with an unsatisfactory result. A, B. The T2-weighted consecutive axial images from the L5-S1 disc level. An extruded disc herniation is noted in the subarticular portion of the left L5-S1 (arrows). The nerve root is entrapped in the left lateral recess of S1. Although left S1 transforaminal epidural steroid injection was performed, the symptoms persisted. The patient underwent a disectomy two months after injection.

• 

  Fig. 6 MRI of a 46-year-old woman. Grade III nerve root compression with an unsatisfactory result. The paramedian sagittal (A) and axial (B) T2-weighted MR images show a left central extruded disc herniation (arrows). The margin of the herniated disc has moderate signal intensity. The left S1 nerve root is not visible due to the herniated disc, as compared to the right S1 nerve root (arrowhead). Left S1 transforaminal epidural steroid injection was performed, but the symptoms persisted. The patient underwent surgery 1.5 months after injection.

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