J Korean Med Sci.  2016 Aug;31(8):1324-1330. 10.3346/jkms.2016.31.8.1324.

Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial

• Lee DG
• Ahn SH
• Lee J

• KMID: 2373763
• DOI: http://doi.org/10.3346/jkms.2016.31.8.1324

Abstract

Transforaminal Epidural steroid injections (TFESI) have been widely adopted to alleviate and control radicular pain in accord with current guidelines. However, sometimes repeated steroid injections have adverse effects, and thus, this prospective randomized trial was undertaken to compare the effectivenesses of pulsed radiofrequency (PRF) administered to a targeted dorsal root ganglion (DRG) and TFESI for the treatment of radicular pain due to disc herniation. Subjects were recruited when first proved unsuccessful (defined as a score of > 4 on a visual analogue scale (VAS; 0-10 mm) and of > 30% according to the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI)). Forty-four patients that met the inclusion criteria were enrolled. The 38 subjects were randomly assigned to receive either PRF (PRF group; n = 19) or additional TFESI (TFESI group; n = 19) and were then followed for 2, 4, 8, and 12 weeks. To evaluate pain intensity were assessed by VAS. ODI and NDI were applied to evaluate functional disability. Mean VAS scores for cervical and lumbar radicular pain were significantly lower 12 weeks after treatment in both study groups. NDI and ODI scores also declined after treatment. However, no statistically significant difference was observed between the PRF and TFESI groups in terms of VAS, ODI, or NDI scores at any time during follow-up. PRF administered to a DRG might be as effective as TFESI in terms of attenuating radicular pain caused by disc herniation, and its use would avoid the adverse effects of steroid.

Keyword

Pulsed Radiofrequency Treatment; Transforaminal Epidural Steroid Injection; Radicular Pain

MeSH Terms

Adult
Aged
Female
Ganglia, Spinal/radiation effects
Humans
Injections, Epidural
Intervertebral Disc Displacement/*diagnosis
Male
Middle Aged
Pain/*drug therapy/*radiotherapy
Pain Measurement
Prospective Studies
*Pulsed Radiofrequency Treatment
Steroids/*therapeutic use
Treatment Outcome
Steroids

Figure

• 

  Fig. 1 Patient flow schematic. PRF, pulsed radiofrequency; TFESI, transforaminal steroid injection.

• 

  Fig. 2 Visual Analogue Scale (VAS) and Neck Disability Index (NDI) scores of cervical radicular pain patients. TFESI; transforaminal steroid injection, PRF; pulsed radiofrequency. *Statistically significant (P < 0.05).

• 

  Fig. 3 Visual Analogue Scale (VAS) and Oswestry disability index (ODI) scores of lumbar radicular pain patients. TFESI; transforaminal steroid injection; PRF, pulsed radiofrequency procedure. *Statistically significant (P < 0.05).

Reference

1. Weiner BK, Fraser RD. Foraminal injection for lateral lumbar disc herniation. J Bone Joint Surg Br. 1997; 79:804–807.

2. Lutz GE, Vad VB, Wisneski RJ. Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil. 1998; 79:1362–1366.

3. Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine. 2002; 27:11–16.

4. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Freeman TL, Slaten WK. Complications of fluoroscopically guided transforaminal lumbar epidural injections. Arch Phys Med Rehabil. 2000; 81:1045–1050.

5. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003; 103:211–215.

6. Kim WH, Sim WS, Shin BS, Lee CJ, Jin HS, Lee JY, Roe HJ, Kim CS, Lee SM. Effects of two different doses of epidural steroid on blood glucose levels and pain control in patients with diabetes mellitus. Pain Physician. 2013; 16:557–568.

7. van Kleef M, Spaans F, Dingemans W, Barendse GA, Floor E, Sluijter ME. Effects and side effects of a percutaneous thermal lesion of the dorsal root ganglion in patients with cervical pain syndrome. Pain. 1993; 52:49–53.

8. Vatansever D, Tekin I, Tuglu I, Erbuyun K, Ok G. A comparison of the neuroablative effects of conventional and pulsed radiofrequency techniques. Clin J Pain. 2008; 24:717–724.

9. Cosman ER Jr, Cosman ER Sr. Electric and thermal field effects in tissue around radiofrequency electrodes. Pain Med. 2005; 6:405–424.

10. Choi GS, Ahn SH, Cho YW, Lee DG. Long-term effect of pulsed radiofrequency on chronic cervical radicular pain refractory to repeated transforaminal epidural steroid injections. Pain Med. 2012; 13:368–375.

11. Spiegel MA, Lafage R, Lafage V, Ryan D, Marascalchi B, Trimba Y, Ames C, Harris B, Tanzi E, Oren J, et al. Developing the total disability index based on an analysis of the interrelationships and limitations of oswestry and neck disability index. Spine. 2016; 41:74–81.

12. Kanemura A, Doita M, Kasahara K, Sumi M, Kurosaka M, Iguchi T. The influence of sagittal instability factors on clinical lumbar spinal symptoms. J Spinal Disord Tech. 2009; 22:479–485.

13. Bogduk N. International Spine Intervention Society. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2nd ed. San Francisco, CA: International Spine Intervention Society;2013.

14. Rohof OJ. Caudal epidural of pulsed radiofrequency in post herpetic neuralgia (PHN); report of three cases. Anesth Pain Med. 2014; 4:e16369.

15. Park HW, Ahn SH, Kim SJ, Seo JM, Cho YW, Jang SH, Hwang SJ, Kwak SY. Changes in spinal cord expression of fractalkine and its receptor in a rat model of disc herniation by autologous nucleus pulposus. Spine. 2011; 36:E753–60.

16. Ito T, Ohtori S, Inoue G, Koshi T, Doya H, Ozawa T, Saito T, Moriya H, Takahashi K. Glial phosphorylated p38 MAP kinase mediates pain in a rat model of lumbar disc herniation and induces motor dysfunction in a rat model of lumbar spinal canal stenosis. Spine. 2007; 32:159–167.

17. Watkins LR, Maier SF. Glia: a novel drug discovery target for clinical pain. Nat Rev Drug Discov. 2003; 2:973–985.

18. Watkins LR, Maier SF. Beyond neurons: evidence that immune and glial cells contribute to pathological pain states. Physiol Rev. 2002; 82:981–1011.

19. Byröd G, Rydevik B, Nordborg C, Olmarker K. Early effects of nucleus pulposus application on spinal nerve root morphology and function. Eur Spine J. 1998; 7:445–449.

20. Brisby H, Olmarker K, Larsson K, Nutu M, Rydevik B. Proinflammatory cytokines in cerebrospinal fluid and serum in patients with disc herniation and sciatica. Eur Spine J. 2002; 11:62–66.

21. Ploumis A, Christodoulou P, Wood KB, Varvarousis D, Sarni JL, Beris A. Caudal vs transforaminal epidural steroid injections as short-term (6 months) pain relief in lumbar spinal stenosis patients with sciatica. Pain Med. 2014; 15:379–385.

22. Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med. 2013; 38:175–200.

23. Tak HJ, Jones R, Cho YW, Kim EH, Ahn SH. Clinical evaluation of transforaminal epidural steroid injection in patients with gadolinium enhancing spinal nerves associated with disc herniation. Pain Physician. 2015; 18:E177–85.

24. Lee JH, Moon J, Lee SH. Comparison of effectiveness according to different approaches of epidural steroid injection in lumbosacral herniated disk and spinal stenosis. J Back Musculoskeletal Rehabil. 2009; 22:83–89.

25. Lee JH, An JH, Lee SH. Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain. 2009; 25:206–210.

26. Van Zundert J, Huntoon M, Patijn J, Lataster A, Mekhail N, van Kleef M. Pain Practice. 4. Cervical radicular pain. Pain Pract. 2010; 10:1–17.

27. Engel A, King W, MacVicar J; Standards Division of the International Spine Intervention Society. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014; 15:386–402.

28. Kumar N, Gowda V. Cervical foraminal selective nerve root block: a 'two-needle technique' with results. Eur Spine J. 2008; 17:576–584.

29. Kolstad F, Leivseth G, Nygaard OP. Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study. Acta Neurochir (Wien). 2005; 147:1065–1070.

30. Razzaq AA, O'Brien D, Mathew B, Bartlett R, Taylor D. Efficacy and durability of fluoroscopically guided cervical nerve root block. Br J Neurosurg. 2007; 21:365–369.

31. Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician. 2004; 7:445–449.

32. Park CH, Lee SH, Kim BI. Comparison of the effectiveness of lumbar transforaminal epidural injection with particulate and nonparticulate corticosteroids in lumbar radiating pain. Pain Med. 2010; 11:1654–1658.

33. El Abd O, Amadera J, Pimentel DC, Gomba L. Immediate and acute adverse effects following transforaminal epidural steroid injections with dexamethasone. Pain Physician. 2015; 18:277–286.

34. Erdine S, Bilir A, Cosman ER, Cosman ER Jr. Ultrastructural changes in axons following exposure to pulsed radiofrequency fields. Pain Pract. 2009; 9:407–417.

35. Hamann W, Abou-Sherif S, Thompson S, Hall S. Pulsed radiofrequency applied to dorsal root ganglia causes a selective increase in ATF3 in small neurons. Eur J Pain. 2006; 10:171–176.

36. Higuchi Y, Nashold BS Jr, Sluijter M, Cosman E, Pearlstein RD. Exposure of the dorsal root ganglion in rats to pulsed radiofrequency currents activates dorsal horn lamina I and II neurons. Neurosurgery. 2002; 50:850–855.

37. Cho HK, Cho YW, Kim EH, Sluijter ME, Hwang SJ, Ahn SH. Changes in pain behavior and glial activation in the spinal dorsal horn after pulsed radiofrequency current administration to the dorsal root ganglion in a rat model of lumbar disc herniation: laboratory investigation. J Neurosurg Spine. 2013; 19:256–263.

38. Van Boxem K, de Meij N, Kessels A, Van Kleef M, Van Zundert J. Pulsed radiofrequency for chronic intractable lumbosacral radicular pain: a six-month cohort study. Pain Med. 2015; 16:1155–1162.

39. Koh W, Choi SS, Karm MH, Suh JH, Leem JG, Lee JD, Kim YK, Shin J. Treatment of chronic lumbosacral radicular pain using adjuvant pulsed radiofrequency: a randomized controlled study. Pain Med. 2015; 16:432–441.

40. Cohen SP, Peterlin BL, Fulton L, Neely ET, Kurihara C, Gupta A, Mali J, Fu DC, Jacobs MB, Plunkett AR, et al. Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness. Pain. 2015; 156:2585–2594.